140: 9 Steps of IVF Center Lead Conversion

PICK UP THE PHONE and 8 Other Ways to Improve Patient Lead Retention

This week on Inside Reproductive Health, Griffin dishes on 9 effective ways to retain leads and turn them into patients- and they’re not what you might think. Listen to hear Griffin uncover the best ways to focus on, and correct, your patient lead process for increased profits and improved patient satisfaction. 

Listen to hear:

•  What you can do today to increase lead retention, at no cost.

• Griffin explain how to head-off no-call-back online reviews.

• The importance of first point of contact, and how it impacts patient experience all the way down the line.

139: Two REIs Debate OB/GYNs’ IVF Capabilities with Dr. Brauer & Dr. Arredondo

Dr. Anate Brauer (REI, co-founder and IVF Director of Shady Grove Fertility’s New York Region) and Dr. Francisco (Paco) Arredondo (Chief Medical Officer and founder of Pozitivf and author of MedikalPreneur) hash out their agreements, and disagreements, on the upskilling of OBGYNs in the fertility space

Listen to the full episode to hear:.

• Dr. Anate Brauer argue that years of training and experience as an REI do not equal OBGYN general practice upskilling, which compromises patient care and increases risk.

• Dr. Francisco Arredondo state that it is taking place already, the need for providers far exceeds supply, and that OBGYNs are capable (and successful), if properly trained.

• Dr. Brauer and Dr. Arredondo agree on where APPs can offload the burden of REIs. 

• Griffin question whether upskilling OBGYNs to handle IVF will create another chasm in the healthcare system.

• Griffin push back that a solution needs to be identified, (after years of overpromising and underdelivering on the increase of graduating REIs), as they are handcuffed by fellowships and educational institutions. 

Dr. Anate Brauer’s Information: 

Website: https://www.shadygrovefertility.com/locations/new-york/manhattan-fertility-center/

Dr. Francisco Arredondo ’s Information:

LinkedIN: linkedin.com/in/fertilitysanantoniotexas

Website: www.medikalpreneur.com

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[00:00:52] Griffin Jones: Can OBGYN do IVF retrievals? Are you good with that? Are you okay with that? You disagree. You the inside reproductive health audience disagree on if non REI fellowship trained OB GYN can do IVF egg retrievals or not. This is one of the things that we talk about today with my guests, Dr. Anate Brauer and Dr. Francisco Arredondo. We try to get down to the exact point that they disagree on and really zoom in on what they think OB-GYNs, that are not REI fellowship training, can do and can't do. There's a whole bunch of things that pile into this access to care argument, and I try to piece them out and I try to elucidate.

Okay. What's the exact point that you disagree? And I think we found that as well as we talk about the duopoly, the duopoly of the pharmaceutical manufacturers, we talk about the shortage of embryologists is that need even greater of a bottle of the bottle neck. Then the shortage of REI is we talk about expanding fellowship programs, which is never gonna friggin happen from my vantage point.

Maybe I'm being cynical, but Dr. Brauer promises to get me somebody that can walk us through that in a podcast episode. And I think these are two of the people to do it. This is a bit of a continuation from the debate that I have with Dr. John Storment and Tracy Keen, the CEO of Mater Fertility, both Dr. Brauer and Dr. Arredondo had listened to that episode as well as some others and felt that they had something to offer. And I think they both did have something to offer Dr. Brauer's of course, with Shady Grove Fertility in New York, she's fellowship trained from Cornell, which a various med fellowship program.

And Dr. Arredondo is the Medikalpreneur is going to be on a different episode to talk about that there are initiatives that he was involved in, including the foundation that he talks about in this episode that I didn't even know at the time of booking. I also didn't know that he sits on the board for Mate Fertility.

And so I feel that should be disclosed. It wasn't disclosed in the conversation. And so I'm disclosing that here, but I feel that both parties really spoke what they truly belief and and they both make strong cases for what they believe in. The shout out for today's episode is going to go to Dr. Matt Retzloff.

I'm sorry, friend. I probably butchered the study that you were recommending that would give us better data on making decisions about the quality of care. So, Dr. Retzloff, if you want to come on the show and spend the entire time talking about what you recommend. I promise to let you to do justice for you there.

So I can't make this debate. I'm not a clinician. We have two good clinicians on here who disagree, you analyze their motives. You do all the psychological analysis that you want, but you tell me, who do you agree with? Who do you think is right in this context and what are we missing? If anything, enjoy this discussion with Dr. Anate Brauer and Dr. Francisco Arredondo.

Dr. Arredondo Francisco welcome back to Inside Reproductive Health, Dr. Brauer Anate welcome to inside reproductive health. 

[00:04:21] Dr. Anate Brauer: Thank you so much for having me. 

[00:04:23] Griffin Jones: Dr. Arredondo has been on twice before. And part of the reason why you have Dr. Brauer is because I have had probably four or five people from Shady Grove on, at this point, and I'm going to be accused of playing favorites, but now I'm going to be accused of playing favorites with Paco too, because this is his third time on the show.

He's going to come back on for a fourth because he's got a new book, medical preneur that once I get finished reading that he and I are gonna go over that, but you're both on, because you each had some points of view on an earlier episode, a couple earlier episodes that I've done. One started off with mate fertility and that got people talking.

Then we had the CEO of made fertility on to talk with Dr. John Storment even before that episode aired. And that you shared with me that you had concerns about what the REI about taking things out of the REI preview and what that means Paco, you had points after that came out where you felt like that there needed to be a physician arguing for the side of upskilling or training OB-GYNs outside of fellowship, but let's start with your concerns not. And just, what was the concern that you had when you listened to that first episode, or just in general about the issue? 

[00:05:43] Dr. Anate Brauer: Sure. So I think my background is I trained at Cornell, which I realize is in New York City, where there are 22 other IVF centers and there is a lot of access to care.

So I understand that we're coming at this from different perspectives, but my fellowship director always said to us when the time I was a first-year fellows. Our field of medicine, more than any other field of medicine has the potential to change society. As we know it right. For better or for worse. And I think that that comes with huge responsibility and liability.

And so it's a big undertaking. And one of the hardest things we'll talk about kind of bottlenecks to access because that's a big part of this discussion. But one of the hardest things I do is counsel patients not just do procedures, but also counsel patients on very complicated endocrine issues that have to do with competing, brokering failures and other things that we'll get into.

And I don't feel like I would be equipped. To treat the patient with the level that they should be treated. If I didn't have the training that I had. So it does concern me this idea of standardization of pair as a CEO of, of Mate stated that said that those words multiple times because each case is individual and all of the training that we've received and experience that we've had, I think helps us get that individual patient to their goal of competing safely.

And so that's my concern here in New York, by the way, what prompted my conversations about this and actually will prompted my interest in being on the start QA committee, which I'm now on, is seeing chart after chart of complications of IVF cycle overseen by general OB GYN who have not been properly trained, who are working for some of these companies that are looking now to scale very quickly.

And so that's what kind of prompted this concern in me. So there you have it. 

[00:07:53] Griffin Jones: Okay. I'm going to come back that I took a couple notes on two different points. You made one about fellows and then another about the complications that you seen, but Paco, when you reached out to me and just said, there needs to be a doctor arguing.

There needs to be an REI arguing for the case of training OB-GYNs outside of fellowship. What did you mean by that? And if I'm paraphrasing correctly. 

[00:08:14] Dr. Francisco Arredondo: Sure. No, no. Yes. I thank you once more for having us and thank you to, and not to be willing to do mental gymnastics here. So I would like to set three things straight before we enter into any debate in one of them is that debates in my view are not to be won or lost.

The baits are to be learned from that's the first thing I want to state. The second one is that if we agree in the context here, that we believe both sides, that human reproduction is a universal, right? That's the other thing that I want to set as a context, because everything else evolves from there.

And the third thing is that there is a difference between clinical medicine and health policy that we asked physicians at the clinical level. We use sometimes not always created at the same, and there are very different interests in individual care versus health policy. And when we have 90% of the needs of the fertility unmet in this country then is when I do argue that we have to think of different models of providing care and among them, we have to explore the possibility to utilize every one a was at the top of our licenses.

So that's basically what I meant. And I would start by saying that it is not my intention ever to replace REI's we don't be ever, but we have to learn from other places, even within our specialty, let's go to fetal maternal medicine, the fetal maternal medicine, which are high-risk deliveries and high-risk pregnancy.

Those guys do not do one single delivery. All of the deliveries are done by OB GYN. They basically handle themselves at the top of the license by managing different pregnancies, recommending guidelines, recommender, and course of actions, and are executed by OB GYNS. And it's the sociologist, the only way they run five or so at the same time is by having extensors like CRNAs radiologist.

They don't do every single x-ray. In fact, they just sit and read the x-rays that the technicians and other people run healthcare. Otherwise. If we have a potential market of 3 million IVF cycles in the United States, and we are currently doing 300 cycles. Even if you crank the production of REI, we will never have all the REI is doing every single egg retrieval that is out there.

So my argument is, and this is the argument of our nonprofit, which is called universities to train people, to do other tasks that physicians are doing, or nurses are doing that can be done by different people at the top of the license that is there. 

[00:11:54] Griffin Jones: I want to let Dr. Brauer and analyze that in a moment.

I want you to start though Paco with what is the limit of what the REI can do? So if you already, I needs to practice at the top of their license. What is the limit to what can be done outside of fellowship training? 

[00:12:12] Dr. Francisco Arredondo: Yeah, so I think I would approach it gradually. The other way it is, there is no question that an OB GYN and a nurse practitioner or a PA with good guidelines should be able to do every single diagnostic step of the fertility patients.

Number two. I think that doing an egg retrieval. For example, I would not give it to a nurse practitioner or physician assistant because they are not capable of resolving a complication bleeding, et cetera, but an OB GYN absolutely can do an accurate very well. There is no reason why an OB GYN can let's put it this way in the last week I spoke with probably 20 different fellows that our fellows out there that are coming out doing 10 egg retrievals in their whole fellowship that it's still to this day, they are reproductive endocrinologists that come out of fellowship without with zero embryo transfers, zero embryo transfers 

[00:13:36] Dr. Anate Brauer: This is an issue write that down Griffin, because that's something that should definitely be touched upon regarding fellowship program.

[00:13:43] Griffin Jones: So I am writing that down. I want you to continue Paco with so every step of the diagnostic process OB-GYNs can do egg retrievals.

What else?

[00:13:52] Dr. Francisco Arredondo: Currently we're doing IUI is playing IUIs in the OB GYN office. And I think that there's no reason why they will not be able to do IUI and again, all under the supervision of a fertility specialist. Now you will have control of, or a guide, several OB GYN and there is a difference between what we call improvement in quality and innovation, because the requirements for improving quality are exactly the opposite to innovation quality requires consistency, repetition, precision standardization, because quality, the enemy of quality is variability. So that is what is required for improving quality. However, for innovation, you actually required the opposite. You require failure variation and serendipity. So we have to be able to dance this delicate dance between improving quality and innovating in healthcare.

And yes, how I see the market right now, or fertility taking certain steps imply that we will take some breaths. But not taking a risk right now, you will imply that will never satisfy the demand. 

[00:15:37] Griffin Jones: So before we go improving the, before we go innovating, now, I want to see in this game of, of blackjack, let's call it and that where we're hitting you one after another, at first OB GYN is doing every step of the diagnostic process, then doing egg retrievals, then doing IUI.

Do you disagree with any of that? 

[00:15:55] Dr. Anate Brauer: I think in general, all of these access conversations are glossing over one major issue, right? The issue with access does not just come down to how many RAs are graduating every year. There are other major roadblocks to access. So the three issues that I see with access are costs and affordability.

Even more than our eyes embryologists. Okay. And then REI is for us at SGS our biggest issue as we're expanding in various markets is not necessarily finding doctors to put into the clinic. It's even more so finding embryologists right. Takes about two to three years to train a good embryologist, to do biopsies and egg set cetera.

So all of these conversations are revolving around how do we get more providers? Did you retrievals to get more new patients in the door? But there's also roadblocks on the other end of that. I'll talk about some of the ways that we are trying to address from those, some of those robots within our organization and why I wish other people would be doing the same work.

I'm happy to talk about that. But one of my that, for example, when you were interviewing the Mate CEO that you were talking about access and costs, they don't take insurance. I have a huge, huge issue with that. And so I think we can not only talk about providers, if you don't talk about whats our solution for costs and embryologist, and a lot of the solutions for cost is well higher general OBGNYs, or would you want it?

And then you don't have to pay them as much as you do an REI by the way, some of my best friends in life are general OB GYN who are unbelievable, amazing what they do. And so none of this discussion in any way, a ding on being a general OBGYN. I also think we should look at our other fields in our space.

So I know some amazing generalists that are unbelievable surgeons. That doesn't mean that they can become GYN, oncologists. And so I think we should have a very clear discussion on what we need to do to expand more trained REI in this country and not only to roll over OBGYN, but also the role of APP.

For example, I do most of my own scans which I know sounds a little archaic, but that's how I was trained. And I'm in New York and my patients want to see me and I liked him the ultrasounds, and I think the more ultrasounds is even better, your retrievals. But I do think there's a role for APPs is, are advanced practice providers to do ultrasound, to do IUI, even to manage IUI cycles.

It doesn't even necessarily have to be a general overview. And I personally do not feel comfortable with the general do and doing retrievals unless they've done thousands and thousands of retrievals or unless it's an REIs physically on site. The CEO has made with saying, oh, we have five REI's on the board who are there by telemedicine.

She also didn't mention who these people are, but I don't know what REI that I know would feel comfortable with the liability of being on a video, walking in GYN, through a complicated egg retrieval, and some that has fibroids, maybe someone that needs an abdominal retrieval, it SDF. We have a policy that if someone requires an abdominal retrieval because of body habitus or anatomy or fibroids, there has to be two MDs on site to do that together in the, or so yes, 99% of retrievals are easy, but when they're hard, they're really hard.

You can be one millimeter away from the illiac I mean, I will not feel comfortable with an OB GYN handling case like that unless I was in the room with them. 

[00:19:22] Griffin Jones: Okay. 

[00:19:23] Dr. Francisco Arredondo: You will know those hard retrievals in advance. Obviously you will not have scheduled them.

[00:19:28] Dr. Anate Brauer: Not if I'm not scanning them.

[00:19:30] Dr. Francisco Arredondo: Huh? 

[00:19:31] Dr. Anate Brauer: Not if I'm not doing the ultrasound.

Right. 

[00:19:34] Dr. Francisco Arredondo: Do you think that an OB GYN will not affect the note by an ultrasound? A fibroid? I mean, I think that the OB GYN are capable of doing that and much more surgery, sometimes more complicated than, than I realized, but that is a debate that we can have, but regarding the issue of REI and the access of costs, I think it is very clear that the lack of production of REI is related to the lack of decrease of cost of idea.

We actually have very high IVF costs because we don't have enough supply. And if you think about any other industry, even in healthcare. Braces, I remember when I grew up only the rich people have raised raises a lot of other plastic surgery, every single one of those procedures has been going down in price.

The microwave was $600. Now you buy for 30. The only thing that has going up is the IVF cost. And it's not only because of the physicians. It is because there is a duopoly on the pharmaceutical industry. There is other reasons that there is no competition, but if there is in now with the consolidation of private equity, it actually will have even less competition that will not be quizzed the price of access.

So my point is that the correlation of access to cost is directly correlated with the lack of providers. 

[00:21:13] Dr. Anate Brauer: Right. So how do we increase that? Right. So for example, we, so I'm part of Shady Grove Fertility, which is a part of a larger organization US fertility, we train, we graduate about six fellows a year. So we now run the NH fellowship program, the University of Colorado's program, and the University of South Florida.

[00:21:33] Griffin Jones: But how many of those are new fellowships? And not like the University of Colorado was acquired by us. Jeff Jones was acquired by us. Jeff, not how many of them are new? 

[00:21:42] Dr. Francisco Arredondo: We need hundreds.

[00:21:44] Dr. Anate Brauer: Right. But hold on a second. Let me just finish what I'm saying. Right? So we support those fellowship programs. We train those fellows, we fund those fellows.

Which I don't see any other non-academic program doing or offering to do. We would love to open more fellowships. For example, I'm here at STF, New York with my partner Tomer singer, who was the director of the residency director at Lenox hill for almost 15 years. Right. So we would love to do that. The problem is there are many hoops and ACG requirements. You're required you to be affiliated with an academic center, which for us in New York, everyone's already taken up. Everyone already has their own fellowship program and they don't want the competition, which is a whole other conversation. It's impossible as an REI and New York city to even get hospital privileges because they don't want to give you privileges because they don't want you competing with them, which is a whole other problem that you really be on the cover of the New York time.

But that's the problem we want to train fellows. We do. I can't speak for other organizations like CCRM or Kindbody or anybody else. We want to train fellows. We are training fellows. We are training embryologist since we took over the Jones' program, we're expanding that training program. But these are the things that we need to be focusing on rather than taking shortcuts and hiring OB GYN and train them to do, what would we do.

[00:23:04] Griffin Jones: But everybody's been saying that for years now, and it still hasn't happened. We're still not adding more of them. 

[00:23:10] Dr. Francisco Arredondo: I don't think that it's taking shortcuts. It's thinking out of the box to re think the model because the truth is being very realistic. If we are currently doing 300,000 IVF cycles with 1500 IVF doctors, and we have required 3 million cycles in the country, when are we going to produce another 10,000 REI?

 We want. We want. Period. I mean, we have to be realistic.

[00:23:45] Dr. Anate Brauer: Right. I think the main issue is that the fellowship programs are siloed within academic programs who have no interest in expanding or working with private practices to expand fellowships because they're perfectly comfortable. In the situation that they're in.

Right. And so that's a major discussion that needs to happen. And I'm still asking the embryology question because my main limit to increasing my cycle number is how many embryologists do I have in my lab? And to me, it's much harder finding embryologists than it is to find an REI. 

[00:24:19] Dr. Francisco Arredondo: And actually in that I would say Griffin to schedule a talk with Tony Anderson.

Who is our lab director and the main person. He has IVF Academy of IVF of USA and that he is going to be incorporated into our University. And basically he presented at the Pacific that after doing a two month training. The outcome is exactly the same as if somebody that has more than one year doing an exam.

He prove it. He has the data is not data that is just mentioned is data, solid data. So we are actually changing the way the training is happening. There is a hybrid training online, and then there is in-person with actual cases. And I think that the academy can produce very good embryologists in approximately four months with all the training.

Well, I'm not an embryologist and this is what my embryologists are saying. 

[00:25:27] Dr. Anate Brauer: You should ask Michael Tucker and Jim Brown, and maybe they can debate each other. 

[00:25:32] Griffin Jones: My job as moderators did keep this a little bit boring by preventing the 18 different topics from going, focusing on one. So I'm going to try and do that.

I do want to come back to Dr. Brauer's point about embryologists later because Dr. Storment afterwards texted me and said, I wish that I had brought that up to although now no, I'm going to save my tangential thought for when we come back to that, I want to, and the duopoly of pharmacies and the fellowship programs, I want to come back to still what you are comfortable with the OB GYN being trained to do not.

And it sounds like, okay, they can do retrievals if an REI is physically in the room and. 

[00:26:13] Dr. Anate Brauer: Yeah. And then that defeats the purpose, right? Because I'm still physically in the room. I still have to physically be in there. They will do the retrieval.

[00:26:23] Dr. Francisco Arredondo: I personally disagree that you don't require a REI to be pressing down the hall? Not even, I mean, not even there because an OB GYN in a simple case, which is what we want to select to give to them. They have the capacity to open that patient. They have the capacity to the tech. When the patient is bleeding, they have the capacity to suture a cervical artery probably better than us.

So now they have not done it. And as I mentioned, there are currently a lot of our REI colleagues when they started practicing, they have done less than 10 equity retrievals. That's what it is in. we are naive and we don't think that that is happening, that we were learning on the train. 

[00:27:09] Griffin Jones: Anate are you not satisfied that an OB GYN could address the complications?  

[00:27:15] Dr. Anate Brauer: I fully again, like many of my friends who were generalists are probably better surgeons than I am I guess I don't understand what the, the kind of, it's almost a perseveration of OB GYN, OB GYN, up-scaling OBGYN and why is that? 

[00:27:31] Dr. Francisco Arredondo: Because we have 90% of the market without cover. We have 90% of the market that is not covered. 

[00:27:38] Dr. Anate Brauer: Okay, so let's talk.

Why are they not covered? 

[00:27:41] Dr. Francisco Arredondo: Because A, lack of access financially, B lack of go live, go of competition because we don't produce and offer REIs and our boards have for 20 years spoke with both of them. Saying that they wouldn't increase access and they have not done it because we have not produced more REIs because there is access to care.

Like there are certain areas that are in rural areas that they want to solve right now. Their practice in private equity will not buy it because, oh, it doesn't provide a lot of revenue there. So those are in insurance coverage is another one and that it is not mandatory. So all those are reasons.

But the main reason, if you look at any healthcare issue is a supply driven market. The more suppliers you have, the bigger the market will be there and we are not supply-driven. 

[00:28:43] Dr. Anate Brauer: So I just want to take those points one at a time. Right? So. And put the, my argument aside for a second, because one let's, let's talk about cost, for example, that's the first thing you mentioned.

So the main issue with costs is lack of insurance coverage. Right? If everyone had insurance coverage, everyone would have access. Is that accurate?

Right? So that's that we should be focusing on. If the, 

[00:29:16] Dr. Francisco Arredondo: if the, if the, if the insurance is given to everybody, not only the ones that work, then it will be covered. So if they don't see universal health care coverage, yes. 

[00:29:25] Dr. Anate Brauer: Your premises I'm from Israel. Originally, everyone has coverage and everyone has IVF pilots.

But 

[00:29:30] Griffin Jones: how does that supply, how does that solve your supply and demand issue pocket? If, if, if, if we're, if, if we're only serving a quarter of the population are actually not a quarter, a fraction of the population and, and that's, that's covered and we still have eight and 10 week wait lists. How does, how does ensuring more people increase access?

[00:29:55] Dr. Francisco Arredondo: I don't think so because you have much more demand, but you don't have for supplies. 

[00:30:01] Dr. Anate Brauer: Okay, so then let's talk about why are there waitlist? So we have, we have, I don't know, 40 something offices now in all different regions, we follow our waitlist very closely. We're not in any, , we're in Colorado, Colorado spring.

We're not, , we're not in the Midwest. So I have friends in Nebraska. I think she has a wait list of two or three months or something like that, which they can get their initial workup done with her OB GYN. And by the time they get to her, , I think COVID has changed a lot. We can do a lot of virtual consults to me.

When, when I talk about access, someone's not going to open you to financially support IVF labs, to be able to argue, to put an embryologist that two minimum, two embryologists there could you need witnessing and all the staff that you need to staff a, an ASC, et cetera. You may have an ASC in a major city and you may have kind of satellite monitoring.

Stations, if you will. And if I train some on whether it's an ultrasonographer or a PA, it doesn't have to be a general OB GYN is my point. If I train a PA to do all the monitoring there, I think I have more than enough time to review those cycles. So that's why I don't know what, why specifically we're talking about the way to solve the access to care issue is trained more overdue in because if I had someone doing monitoring and then coming for me to do retrievals and my partners to do retrievals and I can sit there and do virtual consults all day long, I don't see why, why this is an issue.

I don't 

[00:31:27] Dr. Francisco Arredondo: think that we can, we can, we can not do 2.7 million ed retreat. We can't 1500 people cannot do 2.7 million egg retrievals it's on reasonable is up. It's not possible. I do agree with you a hundred percent. We open a satellite, a hundred percent run by a PA a hundred percent. She saw the patients she's monitored.

She sent them, we do the egg retrieval. We do the transfer could not agree with you more. And that I think that we can set it up here as the basis for agreement that we can develop satellites where everything else. And we can start as a point of view to start training those people, to do the satellites.

Now there's going to be a point that those satellites are going to saturate the egg retrieval bottleneck that will occur, and then we can discuss the next step. But I think that as a first step, we need to train people that. It's comfortable doing all the monitoring, all the counseling and tweaking the medication during the stimulation.

So we agreed that they can do the diagnosis. They can do some basic, 

[00:32:49] Dr. Anate Brauer: oh, I said, I set 

[00:32:50] Dr. Francisco Arredondo: a PA or nurse practitioner or a generalist. It's okay. It's cheaper. Or is less expensive if you use a RPA, but now for an country. I certainly will allow. In fact, there are plenty of OB GYN out there, general OB GYN that are doing that for, 

[00:33:08] Dr. Anate Brauer: with as we speak.

Yes. And I have managed their complications.

[00:33:16] Dr. Francisco Arredondo: I 

[00:33:16] Dr. Anate Brauer: have, I'm not saying there aren't out there and , we've all had complications. 

[00:33:21] Griffin Jones: Did they appear to be disproportionate to you or not? Did they do, does it appear anecdotally, do you, does it seem that you're seeing more complications from 

[00:33:31] Dr. Anate Brauer: hyperstimulation syndrome? Absolutely because they haven't been trained and.

Hundreds of thousands of simulation cycles. And by the way, I totally agree with you Paco. I was lucky enough to train at Cornell where by the time I graduated, I saw more simulation cycles and most attending feat in a year. Right. So I understand which is another issue. Like there's fellowship programs out there that do 200 cycles a year, that's it?

And they have two fellows. They should not have two fellows because those fellows aren't getting clinically trained. I mean, that's a whole other discussion even needs to be 

[00:34:05] Dr. Francisco Arredondo: had. And that would be the second point of agreement, which is we agree that we can train all those people. The second to try to find common ground is that somehow we need to revisit how the people is being trained in fellowships, because we're putting a lot of emphasis of 18 months or 20 months in research when 99% of the people come out and do IVF, maybe we need to track.

So REI. The researchers 

[00:34:36] Dr. Anate Brauer: and the IVF. So 

[00:34:39] Dr. Francisco Arredondo: you'll have now two different tracks and you can produce in one year a good REI fellow in a, that is going to do IVF because by that year, they can do easily a hundred retrievals, easily 50 transfers and seeing their sheriff complications and they can go on. So that's another compromise that I have no problem doing.

But I think in, in, in basically that's one of the ideas or just university that we really need to create. And that's what we've made it a nonprofit, because we don't want to, anybody to mention that we're doing this for profit thing. We are doing this for the firm belief that we think that the United States.

Do not have the healthcare that they deserve at the level of fertility, we have 90% and we need to change that and how we do it, we can obviously have the debate and this, but we need. 

[00:35:43] Dr. Anate Brauer: Griffin the fellowship question and the training. So at SGF, we require any one onboarding. I only have to do two weeks, but we require six weeks out of fellowship and spend it in Rockville.

You're doing hundreds of cycles. Minimum a hundred transfers before you can do anything in any of our labs. And so I, I, , unfortunately some fellows need a mini fellowship. We haven't made a business out of it, but maybe we should, but that's, , 

[00:36:11] Griffin Jones: and answer to your question of why this issue is I w I'm not qualified to argue that it's the most present maybe that maybe dogs are done to is, are arguing that this is the most important thing that we can do.

I'm simply observing that it is one thing that we can do out of many reasons. And the reason why we stalemate in politics very often, we're trying to improve education while the teachers need to, the teachers need to do this while we can't do that until the parents do well. And then you, when you. Go from one issue to another, just nothing ends up getting done.

So it's okay. We take the issues that we have in front of us and try to unpack each of them. I'm definitely not solving the duopoly of the, of the pharmaceutical companies here. And the embryologist, I do want to talk to more, but it's also another issue. Could it be more important than this one that's arguable, but this at least that the number of fellowship programs in the country is another issue, but I'm not a bog.

And and, and, and they still, nobody's still suggested in a bog person for me to talk, to, to do an entire episode soup, to nuts of what it would take to build find me, someone who, somebody listening, find me, that 

[00:37:22] Dr. Anate Brauer: person find the same answer, but 

[00:37:25] Griffin Jones: what's happening right now is that there are people training, OB GYN, generalist, OB GYN.

It sounds like. We have some agreement on what they can do. Some disagreement on the level of oversight needed and the, and the likelihood of complications that come from retrievers. What about the diagnostic piece? And what about OB-GYNs doing IUI? 

[00:37:51] Dr. Anate Brauer: So I think so I would, I would, the first one talks about the diagnostic.

So is it Mitchell? And again, I am in New York city where I treat a very different kind of patient population. I very rarely see a bread and butter facilitation. By the time the patient is sitting in front of me, they've cycled the four other centers. And show up with their like binder of medical records.

And so I don't see kind of the bread and butter. I have a lot of friends who are generalists, who want to send patients to me and in the interim, they're kind of doing a workup. So I do feel like one thing that would definitely help is training is first of all, increasing REI education in general and OB GYN residency, right?

OB residency, four years, I spent a ton of time in antepartum learning all the MFM stuff. Do you want oncology that I, Cornell is a very, I also did my residency at Cornell, very surgical program. I, I went into ODU and to do, do an oncology and then swung the other lines of spectrum. But I spent so much time in OBGY/Onc.

I wanted to do REI and I spent three weeks in REI and this is someone who actually wants to do it. So you can imagine the resident that doesn't care. So the OB GYN is graduating programs right now. Residency programs really know very, very little about REI. So we have residents here rotate with us in New York all the time.

From various hospitals and, and the first step is to just teach them the basic workup. What does it take to make a baby? How do you talk to a patient about it almost from, as in flipping in normal uterus to implant normal ovaries with normal numbers of eggs and genetically competent eggs, right.

Just be at the conversations that the ingredients doing the workup, right. That automatically takes so much off of my plate. And so by the time they're coming to me, they're already kind of packaged up of, okay, here's the basic workup, also doing the preconceptual genetic testing so that they're all kind of set up.

So I'm totally comfortable with an OB GYN doing those sorts of things, then even comfortable with an OB GYN, managing IUI cycles. For example, as long as they're monitoring cycles, I'd actually rather have an OB-GYN working under. Stimulating patients and actually monitoring them than just randomly giving them.

Clomid like, it's candy. Like we see all the time. Right. And you don't even know how many follicles are growing and even an GYN or a PA or an MP doing an IUI at Cornell, which is very tightly managed. I mean, fellows can't even stand follicles that are over 13 millimeters, right? When I was a fellow, unless you were a senior fellow and very experienced and ultra down, but the NPS and the PAs would be the ones doing IUI.

So that's, that's very low risk. I have no problem with that. It's really, when it gets more into the, it's very important for me to counsel a patient on what IVFis, the pros and cons of it, the risks and benefits, the possible outcomes and complications, right? Because it's all about setting expectations.

And I feel like we know all the possible outcomes, genetic testing, which is becoming more and more complex. The pros and cons that are constantly changing every few months, we're learning more and more. And specifically when there's failures talking and counseling patients through that, we know with our eyes, what happens in the lab, most fellowship programs, you do spend time in the lab.

And so those things that take it does take a fellowship for them to learn all of those things, thin lining, but current implantation failure, we're current present the wealth, all of the things that we're still well versus taking it. So those are the cases that I want to manage. I feel comfortable with an OB-GYN managing a simulation cycle, but I also feel comfortable with a PA running through that dosing with me, which takes, , five seconds for me to do.

And I'm even profitable the PA doing the IUI. So that's why I don't, I don't think it even requires training general. I would do am. I think an REI can handle it. Doing more cases. If we, if we're set up in a more efficient way. I also think one thing that we haven't brought up here, which is huge for efficiency is AI, right?

The, we, we at us fertility are, have, are investing a lot of time and money and research dollars into exploring various ways that artificial intelligence can be used. I think one of the best ways it can be used is, and this is for everything from doing an ultrasound, like you can have an MNA, take an ultrasound probe, put it in the vagina and you get a read out of every follicle and what sizes objectives.

Cause there's always subjectivity when you're talking about measurement. So something is a little of that to extrapolating it, to. Dosing a patient's right. And algorithms of looking at hundreds of thousands of cycles and predicting even based on fire cycles that, that patient's done when you should trigger how you should trigger, et cetera, and also into the lab of grading embryos, et cetera.

So I think, I think where the investments should be is training more REI, which is complicated because that involves a bag and ACG made all of those things. We've got to find a way to do it. Training more embryology. And artificial intelligence to make our lives more efficient to solve our problem.

[00:43:09] Griffin Jones: Darn it. He will, he will buy the, it'll start a new one by the end of this podcast 

[00:43:14] Dr. Francisco Arredondo: at 99% of the things. I agree because I agree that we only as a OB GYN rotate one month and the issue is when they pressure you to take vacations in our, in every I in just one month or two months in the whole 48 months of of training, I do agree that artificial intelligence is the future.

And obviously there are already companies out there, like we were just mentioning and all that. I think the key difference, and we agree that we need to train REI perhaps in a more expedite manner. Or in two different tracks, we agree that we can utilize nurse practitioners, physician assistants in order to increase efficiency in the system.

All that I think the only difference that we have is that I feel strongly that a OB GYN can handle equity tremble. And obviously she does not. But in order to dive into that particular question, let's think of other examples within our industry , that you have birthing centers and you have delivery centers and in the birthing center, you're not going to send a patient with a previous C-section preeclampsia and diabetes to be delivered there.

No, you want to send this straightforward case that will have. Very unlikely, a reason to have a complication. And if that thing arrives, you have a system in place to send it to the delivering hospital, which is rare. So it is the same thing in fertility where you can put the simpler cases, especially those that are in rural areas in markets B's.

And C's where a train OB can do the retrofit. And we don't know what is going to be in the future because now in the future, you might get. You send the act to a place where they do. They send this sperm, they do the, the embryo, and now you send the embryo back to the place and anybody can do a number of transfer.

I mean, that could be a potential business model for the future, right? Where you do it. Richard was in one place. You freeze the egg, you freeze the sperm, you send it to a very concentrated laboratory. And you'll create the Ember and you'll send it back. And then you transferred the embryo that is possible.

And now you increase access 

[00:45:48] Griffin Jones: w one point that was given to me, and I want you to apply it on this Dr. Brown Dr. Matt Retzloffemailed me after one of the earlier episodes and says that the only way to really know is to the effectiveness and the safety is and if I'm paraphrasing your point, Dr. Retzloff, you can come on and do your own show.

But he, he was talking about, the only way to really know, is to do a randomized blinded trial of, of outcomes of safety. And because I'm not a clinician because I'm paraphrasing Dr. words, how would that work? How would we, would we really be able to compare the, the outcomes from a board certified.

An ecologist versus the training that's being 

[00:46:31] Dr. Anate Brauer: done, IRB will ever prove that study. And I don't really see patients signing up for that study personally. I wouldn't do that. So, I mean, I think it's, I still am having a hard time wrapping my brain around this conversation, even being a conversation and the word upskilling, which I had never heard that word before a year, 18 months ago, , 

[00:46:55] Griffin Jones: I adopted the word to distinguish it from fellowship training.

[00:46:59] Dr. Anate Brauer: I understand. 

[00:47:01] Dr. Francisco Arredondo: Well,  what happened? What happens in any other country in the world, in Spain, which has been a leader of fertility for years, Spain and France in Eataly in any other place, there's no fellowship, they finished and they go through a certificate or they. And mentoring. I don't know if in Israel there is a fellowship, is there a fellowship in Israel, 

[00:47:28] Dr. Anate Brauer: but they're yes, but they're, they're also required to continue practicing general OB GYN and to take call because it's a, it's a socialized system.

So they see their patients after hours. They do new patient consults, like at 11:00 PM. 

[00:47:43] Dr. Francisco Arredondo: But in order to do an REI, do you have to go through a 

[00:47:45] Dr. Anate Brauer: fellowship? The practice? Yeah. I don't know if it's an official fellowship. You're definitely certified in fertility, all these things that you're mentioning.

They're still training programs and they're not six week training programs. I mean it's years of training. So, but at the end of the day, it's not a new fellowship program. Right. Did you believe that a really good general OBGYN should be take to be cutting out cancer. 

[00:48:10] Dr. Francisco Arredondo: But I would not compare, I would not compare an egg retrieval with the level of complexity of, of a surgery of cancer.

[00:48:18] Dr. Anate Brauer: The liability is similar. I mean, don't feel like our field has the highest liability pretty much at any field. 

[00:48:27] Dr. Francisco Arredondo: I don't think so. I disagree with that. The the premiums of REI are very low compared 

[00:48:33] Dr. Anate Brauer: to the 

[00:48:35] Dr. Francisco Arredondo: liability. That's how it's based. The liability. The liability is based on how likely are you to be sued.

And, and the premiums are fertility. They are very low, very low. I mean, compared to high risk OB, those are high. 

[00:48:49] Dr. Anate Brauer: I feel like what we do and the counseling we offer and the potential issues in the lab are extremely high liability. And so I personally would want to manage those liabilities myself rather than managing someone else's life.

[00:49:06] Griffin Jones: We can bring Dr. Katz on for a liability episode to examine that. But Paco, I want to put something on you because a lot of this conversation might be overlooking second and third order consequences with regard to access to care that come from training. OB GYN is like, I don't know what their overall workload and wait lists look like right now, but I don't think most OB-GYNs are sitting around waiting for new patients.

I think they have case loads and workloads that are pretty full, full. I could that it could be an assumption that needs to be tested, but either way I think it's one we were overlooking here. So if we solve for access to care with regard to fertility treatment, by bringing more OB GYN in to do some of the purview of the REI, then aren't we creating a shortage of care somewhere else in the OB GYN sphere?

[00:49:58] Dr. Francisco Arredondo: I, I don't know. The numbers on the OB GYN, how many are needed? I think that overall, if you look at the statistics by 2045, we are going to have like 70,000 a shortage of physicians in the United States. No matter what specialty you're talking about, because again, we're not producing enough. The, the medical schools are not producing enough physicians.

But I don't specifically to your Western. I, I don't know. We may. But the, the point here is that basically the big disagreement that we have is if an aria, if a OB GYN, after doing 50 or 100 supervised egg retrievals, if it is not capable of doing ed retrievals for an IVF clinic, my answer is yes, if that person and I don't know what the number is, 20 5100.

Which in certain clinics, that person can be trained two months after doing that, it can, that person do equity troubles for you. Absolutely. Absolutely can. In fact, they're are doing it right now. 

[00:51:09] Dr. Anate Brauer: Yeah, I guess my, my question goes back to Griffin. The point he just made, which I still don't see how this specific concept of upskilling solves our issues, because who's going to who we're going to take these jobs.

And we already see that happening. Our residents who GRA, who wanted to do REI, who didn't match for whatever reason. And now this is what they do. And then they get to put on Google that they're a fertility specialist and market themselves in that way. And now you're going to run into a shortage of generalists, which there's already a shortage of generalist generalists, definitely in this area.

I can barely get a patient in to see an OB GYN. Larger problem personally, I would rather train ABPs to do ultrasounds and help me with monitoring and make mission so that I can say my lane and do what I need to do and not take away from any other specialties who, who have their own issues with, with access.

And the other big concern I have is creating a two tier system of care, which we already have in this country clearly. Right. And we see it with cancer, for example, right? The main cancer centers. If you have cancer, you want to go to the best place flown, , you want to go to Texas MD Anderson, there's several big centers in the country you want to go to, you're not going to find it in small town USA.

I mean, I grew up in Memphis, Tennessee, so it's not like I grew up with, , so, so much access around me. Right. And so I do worry about. Giving one part of the population, kind of a water down version of what we do. And one part of a population, an elevated version of what we do the argument against that is, well, you're giving one part of the population, no option and other populations, the best option, but there's something to me just wrong about just because someone lives in a certain place or doesn't have enough money to afford the bad that, that you're potentially giving them a less safe experience.

And 

[00:53:17] Dr. Francisco Arredondo: we don't know if he's let's save. And I would say, we don't know if it let's save. And I would say that if we take a risk, we may fail, but if we don't take any risk, for sure, we will fail 

[00:53:28] Dr. Anate Brauer: to cover everybody. I'm happy to take risks, but I'd rather do it not with upselling of doing.

Well, what I mentioned before, I'm happy to send that set up satellite monitoring clinics, and 

[00:53:42] Dr. Francisco Arredondo: we have proven that that works and delivers the same 

[00:53:47] Dr. Anate Brauer: actual care, so that can work, but I still don't want to solve our problems. They 

[00:53:53] Dr. Francisco Arredondo: are randomized controlled trials where nurse practitioners do embryo transfers versus REI in England, randomized control trials.

Exactly the same pregnancy rate. Exactly the same pregnancy rate nurse practitioners in, in, in in England doing embryo transfers versus 

[00:54:14] Dr. Anate Brauer: res so, okay. So do you feel like we should even have any fellowship programs at all? I mean, everyone could be trained then what's the point of fellowship programs with everything can be, everyone can be trained to do.

Exactly the same thing. If you have any degree or any letter behind your, behind your name? Well, when 

[00:54:31] Dr. Francisco Arredondo: you go now, you're talking about medical education. That's a very important point. So the traditional medical education is based on pedagogy, which is training kids, the dietary pediatry, that's pregnant kids.

The new in, we don't learn like kids will learn by adults, which is unprovoked. And that is by doing things. And you can go and look at medical education. And the best way now is not to saturate people with theory and books and stuff, but it's to give a minimal basis and do things and do things and do things.

So that's why I would say that I will feel very comfortable if I give good basis to an OB GYN and I will train that OB GYN with supervision. To do 50 ed retrievals. It's an experienced surgeon already. I will feel as comfortable as a fellow that sometimes just finished 10 or 20 Avery Tribbles. He has a lot of information, but it does not have the experience or rather the ability to solve a problem.

I am talking specifically about this task. I'm not saying handling all the things I'm talking about. This. I feel very comfortable doing 

[00:55:54] Griffin Jones: it. So I want to let each of you conclude how you want it to, before we do them, I'm going to give you each an open thought to conclude on, but let's hit the embryologist question for a second, which I'm, this is completely anecdotal, but we have strategies based on clinics, different needs and capacities.

And I'm talking about my firm is a creative and biz-dev firm and it seems to me like clinicians hit their capacity first and then embryologist hits their capacity. It seems to me, this is very anecdotal that across the board is generally speaking as possible. The embryologist really, we hit that lab capacity some time after the COVID reopening sometime in September of 20 in the fall of 2020.

And so, but it, it seems to me like they're pretty neck and neck. Maybe the REI bottleneck is tighter, but they're, they're probably equal now, but why not solve the. Problem first Pacoor is, is this, is the embryologist, how is it not more pressing than the REI issue? 

[00:56:58] Dr. Francisco Arredondo: Well, I think that you have to also look at AI, , not that umbrella just will be replaced, but there is a lot, there is the pipeline three to four companies looking at doing the umbrella in a box.

So, and the other thing is not only producing embryologist, but producing umbrella in a way that is lean managed. For example, right now everybody's checking their embryos and they want, and they three, and then they find who you really need to do that. 

[00:57:28] Dr. Anate Brauer: But when we 

[00:57:29] Dr. Francisco Arredondo: used to write one, three and five, now there's people not even checking them until day five or do put them in the editor scope and they just look at it that is working efficiently without changing the effectiveness.

So , one of the things here on, on, on lean management is that you have those two levels. And you have a cost. So how can we produce the same outcome with less cost or how can we remain with the same cost and improve the outcome? And here on the embryology question, you may pray, but actually they might not need as much in five years because AI may catch up with us.

Now you have a lot of people sitting there.

[00:58:16] Dr. Anate Brauer: I don't think I will catch up that bad. I mean, I think it's moving fast, but I still think we'll also always need embryology. Not for us in New York. I'll tell you that we are bottleneck has always been the lab. And so we really had to hire me. Now we have seven embryologists here, but. You really had to staff up and it's, and it's tough.

And so that was always our bottleneck and that was the bottleneck it for now. And that was the bottom line at NYU. I mean, everywhere I've been, that's been the bottleneck because in REI I can always add another new patient slot. I don't mind working hard and I don't mind, , seeing the patients and adding onto my schedule.

I have no issue with that, but the lab I, , in the lab is safety. It's I want my lab to be happy obviously, and feel like everything's being done safely. So I do think a lab is almost a better book, bigger, if not the same bottleneck 

[00:59:04] Griffin Jones: Anecdotally, I don't see REIs leaving REI. I'm seeing embryologist leave the lab, which is crazy to me because they're so in demand, we have embryologists applying for jobs at my firm.

I'm a biz dev and marketing firm because they just don't physically 

[00:59:18] Dr. Anate Brauer: want to be. I said, you send, send me their CV. 

[00:59:22] Griffin Jones: They don't want to be in the lab. They don't want to, they, these are 20 somethings that don't want to, they don't want to work long hours, one and two. They don't want to be in a physical location.

That's a 10 by 12 room for, for however long I'm going to let each, I'm going to let each of you conclude Dr. Arredondo, let's start with you. And then we'll go to Dr. Brower. How would you like to conclude your points? 

[00:59:47] Dr. Francisco Arredondo: Yeah, we'll start with your PaCo. Okay. Now, I mean, just basically I, we believe in, in democratization of IVF, we believe that every single human has the right to be reproduce.

And that is. International and universal human, right. We believe that we are falling short in the United States and that we have to think out of the box to rethink and reshape the model of how we practice medicine without ever compromising quality and without ever compromising safety. And we believe that we've been practicing fertility the same way for 40 years, and it is time to rethink how we do it.

We believe that part of that is to consider training physician assistants and nurse practitioners to do some of the tasks. And if we want to meet that demand of 3 million IVF cycles, we all to train other people to do egg retrievals. And we believe that OB GYN are a good candidate to do that.

[01:00:54] Griffin Jones: Now, how would you like to conclude? 

[01:00:56] Dr. Anate Brauer: So I agree with most of what Dr. Arrendondo has said today. I do think we have a major access problem. I also believe that repositioning is a human right, and everyone should have access to it. I don't think that the problem can be distilled and easily solved by one issue of training.

Would you answer, did you  do retrievals? I think as I mentioned before, the issues of access involve cost. Providers and embryologist, and the only way we're going to solve those problems is by increasing training programs, which is the long game. And in the short term, becoming more efficient through advanced practice providers and artificial intelligence and technology.

[01:01:35] Griffin Jones: You're both very good sports for coming on. You're both also advancing this discussion in the field by being able to do so in good faith. And so I appreciate both of you doing that and that hopefully we can use this as leverage to get somebody we're bringing ABOG to come in and do an episode about what it would be to accredit a REI fellowship program from soup to nuts.

Thank you, Dr. Arredondo. Thank you, Dr. Brauer for coming on Inside Reproductive Health.

138: Retirement and AI coming head to head in the IVF Lab with Dr. Carol Curchoe

Dr. Carol Curchoe, ART Compass director and reproductive physiologist and embryologist, speaks with Griffin Jones about the future of artificial intelligence in the IVF lab, shares her thoughts on how it could be the solution to the ever-present threat of embryologist burnout, and what technologies could take the place of old school, antiquated monitoring systems. 

Listen to the full episode to hear:

• What will happen when the big names in IVF labs retire (soon), and who will be (or won’t be) replacing them.

• Why the idea that technology hasn't advanced in the IVF lab is a myth

• What solutions AI presents for IVF lab quality control, and how we universally implement them. 

• How the tech gaps in IVF lab management are overburdening embryologists everywhere, and how this can, and should, be solved.

Dr. Carol Curchoe’s Information: 

Linkedin: https://www.linkedin.com/in/carol-lynn-curchoe/

Website: https://artcompass.io/

Inside Reproductive Health is sponsored by EngagedMD. For technology that educates your patients with true informed consent, visit engagedmd.com/IRH for 25% off your implementation fee.

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Transcript

[00:01:00] Griffin Jones: There's a massive wave of retirement coming from IVF lab directors and different techniques in the lab are helping or harming IVF success rates. And we often don't know which is which, or by how much, because we need artificial intelligence to integrate into a single system.

This is at least according to my guests, Dr. Carol Curchoe we talk about these concepts as well as the idea that technology hasn't the idea that technology has an advanced in the IVF lab is. The tech needs to be adopted to light and workload because embryologists are burning out and they're leaving the lab and even trying to work for people like me.

And we also talk about venture capital and the lack of funding in the IVF space and, and especially for female founders. And we talk about all of these points and I hope you enjoy this because I am doing more content about the lab. Like I promised you that I would please enjoy today's episode of inside reproductive health Dr. Carol Curchoe. 

Dr. Curchoe Carol welcome to Inside Reproductive hHealth. 

[00:02:04] Dr. Carol Curchoe: Thank you so much for having me. 

[00:02:06] Griffin Jones: You've been up to a lot recently. I saw you at PCRs recently, you had some data about things going on with lab staff and quality testing. And maybe even before we get into that, maybe give us just a little State of The Union of, of how you're seeing the IVF lab nowadays.

And what do you really want to talk about? 

[00:02:30] Dr. Carol Curchoe: Yeah, so my main focus in life is on brain new technologies to the IVF lab. So we are at a pivotal moment in IVF technology where we have. The first generation of embryologists slated to retire. And this is what I call the great gray rhino in the room. So this is the threat that is lurking in the room, that is mostly going by unnoticed. Although I think now this is what everybody's talking about. So the brain drain that's coming to the IVF industry is imminent. And one of the ways that we bridge the gap between first generation embryologists and second or third generation now, maybe fourth generation embryologists, we're getting on 40 years in IVF, right?

And each decade sort of brings us a new wave of fresh graduates and fresh people. Who've trained up under different methodologies and protocols and ideas and ways of thinking in the IVF lab. The best way to bridge this and to really translate the knowledge from the first generation of embryologists all the way to the brand new generation is through the use of technology.

So that is my main focus these days, other than making expensive science babies for infertile couples. 

[00:03:53] Griffin Jones: I was just bragging to you before we started recording that I've included more embryologist lab staff lab topics this year, I think, than in the previous three years of doing the show combined. And then I realized, as you're talking about this brain drain, like I haven't thought about.

Second about, I just did an entire generational grid. That was part of my talk at PCRs about the changing of, I talk about the donors, the patients, the retiring partners, the fellows. I didn't say anything about the lab. So here I am being like, oh yeah, I got way more lab stuff than I ever did before. And then meanwhile, totally neglecting.

[00:04:33] Dr. Carol Curchoe: Yeah. 

[00:04:33] Griffin Jones: Thinking about the lab on either side of this coin that apparently you and I are both thinking about. So let's talk a little bit about the, the brain drain. And do you have like any kind of numbers or when is this waterfall gonna start hitting? Like, is it already hitting, are we seeing the embryologist retire now?

Or are they about to retire as, are we going to see a peak? What's that like? 

[00:04:53] Dr. Carol Curchoe: Yeah. Yeah. So the peak retirement is coming, but what we're seeing now is that they're anywhere from five to 10% of baby boomer generation embryologists are already past the retirement age and they're hanging in the industry either because of lack of somebody to take over their lab or the multiple successive economic failures that the us has had over the past 15 years, which has drained everybody's retirement savings, maybe they're not capable of retiring yet, but the people who are retiring direct multiple IVF labs, and I can think of several big name, IVF lab directors who are directing at least five labs piece who are going to be retiring. So it's not just a sheer numbers game of people who are directly retiring, but each one of those people are going to be directing multiple IVF labs. So if you can think of five big name IVF lab directors who will be retiring in the next five years, they are each directing five IVF labs. So that is going to be 25 openings that are coming onto the market.

And when I see the numbers of people who are getting new HCLDs, which is the certificate that you would need to direct an IVF lab, right? I'm not seeing the same number of HCLD lab directors being produced each year as what we will need to fill the market. 

[00:06:34] Griffin Jones: So if nothing changes, if there's no intervention than what's going to happen, if there's no intervention to increase the number HCLDs then what are we looking at happening in the next five or so years?

[00:06:48] Dr. Carol Curchoe: Yeah, so I think what we're seeing is in the industry in general is kind of a tendency to become more corporate and for bespoke IVF lab practices to be all gathered under one sort of corporate umbrella. And then I think from what I'm seeing is there are brand new IVF lab directors who go to work for these large corporate networks.

And then as brand new IVF lab directors, they're being asked to oversee more than one lab in the network. And so I think that can kind of be a problem for brand new IVF lab directors who don't really have the experience of many years of, of IVF lab directing. And then the other possibility that I'm seeing a lot is the, the rise in offsite lab directorship.

And when we're talking about quality in the IVF lab, a certain amount of oversight that is necessary for the quality to remain high across the industry, or even increase if we're talking about quality improvement and doing even better than we've done before. And I believe we are going to need to do that because of the rise in demand for IVF and the number of IVF cycles is increasing incredibly.

[00:08:13] Griffin Jones: Yeah. Are you worried about the quality from one, either someone who's not experienced enough overseeing too many IVF labs or from one like somebody having to do it remotely from so many different sites, what are the quality implications? 

[00:08:34] Dr. Carol Curchoe: Yeah. And I think that you can open the news, almost any day of the week, it seems like now, and to see some kind of horrific news story coming out of the IVF lab at PCRs, there was actually a talk. 

[00:08:46] Griffin Jones: One a week?

[00:08:47] Dr. Carol Curchoe: Once I hear it, it seems like it's happening so frequently nowadays, right?

[00:08:53] Griffin Jones: That maybe I'm not reading the right news sources that once a week seems like a lot, but what you were about to say an example. 

[00:09:00] Dr. Carol Curchoe: That's an exaggeration, but PCRs there was that amazing talk about risk management and the IVF lab. And this speaker was very careful to point out that the majority of the risk in the practice is actually coming from the IVF lab.

So four times the amount of risk is coming from the IVF lab than anywhere else in, into the practice. And IVF it's one of those things that you really, there is no room for error. You really do have to always get it right of every single time. And so when we're talking about scaling the number of cycles in the US one of my favorite people who has some very compelling, logic and numbers around how many cycles we are doing and how many we're going to do is David Sable.

And he talks for example, a lot about how you could come up with different name combinations in various states, all over the country, name and birthday combinations, and then how they could be the same. And when we're talking about embryos and eggs that are shipping all over the country, just for example, having a unified system of patient identification where each patient has an established unique identifier that everybody else agrees to, kind of like a car driver's license, right? Like when I cross state lines, that license is going to be my identification, no matter what state I'm in, and it's going to be respected and unique and uniquely identify me in a bigger system that someday, I hope I never make it into that system of them being able to tell if I have a ticket in a various state, but.

[00:10:45] Griffin Jones: We are a couple of short analogy. They're going to know all the crap about you and me and everybody listening and going to be in a credit score and you'll all want it. Everybody, you'll all want it because it will be traded for something that's valuable to you.

Either being able to purchase things more quickly or get services tailored more accustomed to you, or whatever it might be be appearing to be a better citizen. You'll all get that we're digressing. This is like the second time in two months that I've got that I've gone on this, this like futuristic time I did it on Dr. Bruno Gaston’s episode, too. But you are talking about something like, so you're in my understanding correctly, you're proposing a kind of solution that helps identify quality across the field.. 

[00:11:35] Dr. Carol Curchoe: Right. And so that there and there are many people proposing different solutions. So there's the IVF open group proposing the patient ID identification solution.

There's the Tomorrow Robot who is proposing the cryo storage solution of the future. And there are many people, many different groups working in artificial intelligence and within my role in artificial intelligence. So we have a lot of very loosely structured data and IVF, and mostly it's all sitting in on paper documents in binders, hundreds of binders in every different IVF lab.

And, my platform, our compass was created to basically have data, stop going onto paper and start going into the computer where it's structured and can be interacted with by artificial intelligence systems. So my platform does a lot of different things along the quality assurance spectrum, including an embryo embryologist training competency and staff related quality assurance.

It's also very helpful for brand new IVF lab directors, because it's bridging that knowledge gap between the baby boomer generation and brand new lab directors or brand new embryologists. 

[00:12:57] Griffin Jones: So I'll ask some questions, which is either born from being devil's advocate or ignorance. And the audience might not know the difference between the two.

I don't know the difference between the two half the time I'm asking you something because I want to poke at it, or because I really don't understand it in this case. It's probably a little bit of both. Why not the EMR in this instance, what is insufficient about the EMR for storing that data there?

[00:13:21] Dr. Carol Curchoe: Yeah and it's a really good question. So EMR, generally electronic medical record system most of the EMR on the market were created 30 or more years ago, and they have been kind of tasked with keeping up with this ever changing landscape of the IVF lab. And they have mainly been created to manage the clinical side of an IVF practice. So they do things like handle insurance and patient calendaring and appointments, the physicians appointments with the patients, so that, physician and staff will have a calendar of what is going on that day with the patients. And also the medication ordering from the pharmacy.

So none of those things have to do with the IVF lab. So on top of the IVF lab cycle management at the heart of every IVF lab practice really is the quality control and quality assurance. It's sort of what elevated IVF from being an art to being more of a science that we know exactly what's going to happen if we do exactly these defined things in the IVF lab, and we can make it predictable, reliable, robust, and effective for the patients. So there's a whole suite of quality management items that overlay everything that happens in the IVF lab. And that's going to be everything from training and competency.

To what happens with your instrumentation or your environment on any given day? We know a lot more now than we know in the beginning of IVF. So we know for example, that using alcohol based hand sanitizers are not good for embryos in the lab. We have to remove those VOCs from the air in the lab.

And so tracking things like how many times our IVF lab door opens and closes and how the pressure in the IVF lab changed and how many times the incubators were open and closed. All of those environmental parameters add up to impacts various impacts on IVF cycles. 

And then it goes all the way through.

[00:15:31] Griffin Jones: How do you track all of those? 

[00:15:32] Dr. Carol Curchoe: Exactly.

[00:15:33] Griffin Jones: I could see like the alcohol sanitizers on the hands it's. How would you even know to hypothesize about that? To look for something like that? And so I'm like, how do you decide what to track to? How do you track it? 

[00:15:49] Dr. Carol Curchoe: Yeah. And it's really, really difficult because there are as many different ways and things to track in an IVF lab as there are embryologists in the United States or in the world.

And so if you compare what any two labs are tracking, and there was a really nice publication a couple of years ago that did this, they looked at 36 different labs and the instruments that were being quality controlled, and it was highly variable. Nobody knows what to track or if it's significant or how many times a day, for example, do you monitor it? So whenever you can go into the lab and you do quality control, you might do it once a day, or maybe every time you walk by an instrument, you might glance at the sensor and see that it's within range. But a lot of these things could be done much, much better if we take the power of computer science and artificial intelligence, I can see a web of smart sensors throughout the IVF lab that are collecting data all the time. Then you combine that with the inputs from the embryo incubators and the , for example, the cryo storage tanks that the tomorrow robot is creating with many, many thousands of data points of continuous monitoring.

So all of that is going to be much, much better than what an embryologist can do. And honestly, embryologists are overburdened with the amount of work that we have. We really need computers and sensors and AI to start taking some of the workload and actually doing it much better than we ever could. So there's no way we can continuously monitor what's happening in the embryo incubator at most, that can only be done a few times a day.

[00:17:32] Griffin Jones: What's impeding technology taking over that workload right now. Is it the technology itself? It's not there yet. Is it regulation? Is it like adoption? What's stopping it from happening now?

[00:17:47] Dr. Carol Curchoe: Yeah, and I think there are solutions that are coming out onto the market where we've seen a really great innovation has been in the electronic witnessing space.

And like different electronic witnessing systems that are watching every step of the process and making sure that, for example, we're not mixing eggs and sperm from two different couples that don't go together or that when we thought the embryo from this patient, we're putting it into that same patient's dish before it gets transferred to the, that patient.

So that whole process now is starting to be electronically witnessed, but these technologies are definitely maturing. I wouldn't say that there are all the way in maturity yet. There are kind of gaps with each one of them. And then I really think one of the biggest things is how does everything integrate together into a single system right now, most manufacturers don't want to play well with each other.

So you might have alarm systems for your tanks. You might have alarm systems for your incubators. And all kinds of various other monitoring systems, but they're all separate logins and they don't talk to each other and they don't share the data. So one of the things that I like to think about is when you log into your Gmail and you click in the upper right-hand corner, you get all of the apps that Google has, you get your drive, you get your calendar, you get any apps that you yourself have, have integrated into that little platform and really that's what IVF labs need. So the EMR is just one small part of the data management in an IVF lab. And then particularly you have technologies that go all the way through the patient management side.

So managing the patient journey, the patient consents the patient calendars patient education and how do you deliver the results of your IVF lab cycle to the patient.

[00:19:51] Griffin Jones: Well, that analogy that you used is also self descriptive of why so many of these companies don't want to integrate with each other because they all want to be the Google in this instance that you used, Google is the perfect example to use because it's Google maps, Google drive, Google docs, Gmail, all of these things that Google assistant, all of these different apps that are within the Google ecosystem.

And, and so people are like, well, we, we want to, we want to be the Google. So before we talk about how to integrate into a single system, I want to ask you more about like the gaps. So you were saying that witnessing is something that has advanced a lot, and the technology is a little bit more mature there than maybe in some of the other w where are the gaps.

[00:20:43] Dr. Carol Curchoe: Yeah. So I think from my perspective, a lot of the gaps are coming from the management of IVF cycle data. It is mostly still done on paper. And for example, when the PGT company gives the genetic testing results to you, that will come to you in a PDF. And so when data is generated, it tends to be static.

It can't be interacted with, and it's very sloppy and unstructured. The thing I like to talk about is for example, like when I want to order something off of Amazon, I just opened my app. And I know that like paper towels in my house are running low because I have this subscribe and save feature and the Amazon app, and then it's, one-click ordering right. Or it's set up to automatically be delivered.

So that's another experience in the IVF lab that is being mainly handled manually. You have an IVF lab supervisor who kind of calculates in their head, how many cycles we're doing, how many cycles we're going to do this month? And then the volume and the amount of reagents that will be needed to not run out of anything.

And that's a process that is very time-consuming. It creates a lot of friction and it could be as simple as one-click ordering an inventory. If there were some smart products that could step in and fill that gap. 

[00:22:16] Griffin Jones: So, how do you envision all of this being integrated? Tell us Larry Page, how does, how does the Google drive and the Google docs and the Google calendar and Gmail and everything else from the lab world integrate in one single system?

[00:22:34] Dr. Carol Curchoe: So I think google didn't, I'm not sure they really developed all of that, or if they went out and bought a best in class solution and then slotted. 

[00:22:42] Griffin Jones: Did plenty of both Carol. 

[00:22:44] Dr. Carol Curchoe: Plenty of both. Right? 

[00:22:45] Griffin Jones: Plenty of both. 

[00:22:46] Dr. Carol Curchoe: So we could be just waiting for that one person to take the vision and really execute it. But one of the other things that I find compelling when David Sable talks about what is IVF going to look like in the next 20 years? He talks a lot about building the IVF super highway. And so right now, the number of IVF clinics that there are they kind of liken it to the old system of country roads, right, where now we have all these country roads and they need to connect into what is really the IVF super highway.

And it's a brand new system that is built for high volume and high capacity in with these best in class solutions. And so, I know that there has been a tendency in the industry right now to be attracting a lot of private equity and building these new sort of forward-thinking networks.

Right. IVF labs that are brand new. So obviously kind body is a good example here and then her fertility and in the UK. So it's definitely going to be very interesting to see, like ultimately what happened with the super highway project is you had a president who put together a, a package at the federal level to build it because it's bigger than what one state could do by itself.

And so how this Federation of IVF labs and the industry of IVF itself is going to continue to be pushed forward without a federal level project or federal level support. I'm not sure, but. 

[00:24:32] Griffin Jones: Well, let's stick with it. I love sticking with people's metaphors. I love using people's own metaphors to like, tweak in and ask these questions.

So, one president that president being Dwight D Eisenhower coming up with the interstate program, late forties, early fifties connected the United States together, advanced mobility, like we had never seen before on the planet. Some cons that came from that, including demolishing entire cities and neighborhoods, including those, like in places where I came from.

And so what are some of the, the doubt? What are some of the risks and dangers that could come from this? 

[00:25:10] Dr. Carol Curchoe: Yeah, and I absolutely hear that. I think so one of the risks and dangers is that the IVF process could actually stagnate because you have these, this sort of way that things are done. And then maybe from it because there are investors and everybody needs to make money and it has to happen this specific way. So it can kind of curtail your scientific freedom, right. To be in these, in these large corporate networks. And that's an argument that I've, I've heard a lot that embryologists nowadays are very much just kind of like technologists, right?

They're given the protocol and they're told what to do and they have to come in and do it the same way every day. And that can be seen in a negative way, or it can be seen in a positive way, right? On the patient side. The patient is assured of what they're getting because the corporate network does things in a certain way.

You're not going to get experimentation directly on humans in many IVF labs. Now. And I think everyone would agree. That's probably a good thing. In the early days of IVF, we were literally experimenting directly on people and embryos for what could happen. And so things are different now. And I think everybody agrees that that, that aspect of it is probably good.

I think there's just in the management of people, that aspect can kind of get lost when you do a huge corporate network. It becomes very difficult to manage staff the further away from the nucleus of the company that you get. And I think you start to get the communication is a little unclear and the path to your career path.

For example, it can be a little unclear in a big network like that where you might have a lot of potential in a very small clinic to rise very quickly and become the lab director and maybe even become a partner in the clinic. And that kind of thing is not going to happen in a corporate setting. Right?

[00:27:24] Griffin Jones: You might be making some decisions about what you want to implement for your practice. And I'll give something for you to consider. You may have been thinking about EngagedMD for a while. You may now be among the minority of practices that are not using EngagedMD. But think about losing even one of your linchpins on your staff, even just one of them, because they've had it, they're too burnt out.

That's what I'm seeing as a hiring manager in this marketplace, people from your clinics, embryologists nurses, mid-level providers, even. Are applying to companies like mine because they want to get the heck out of the clinic and they want to get the heck out of the lab. They're burnt out. There's only so much that you can do.

You're trying everything to hire more people. You're also, you want to lower their workload, but you have such a high patient. All we can do is implement technological solutions. In many cases, to lighten the workload. And some technological solutions are really, really proven. One that's really, really proven is EngagedMD, ask anybody that uses EngagedMD.

You don't have to take my word for it. Ask anyone that uses EngagedMD, and that's probably going to influence your decision, but still mention that you heard it on the. Well, you heard it from Griffin Jones because you'll get 25% off of your implementation fee. If you do go to engagemd.com/irh, but in any event, don't do it for me do, it because we're all in danger of losing the linchpins on our staff right now.

And if there's something that you could have done about it, you're going to be kicking yourself. And one thing that you can do about it, if you haven't done already is to look into EngagedMD. EngagedMD.com/irh. Now back to the show.

One of the things that you got my attention with when we were emailing about this episode was that I do hear people say a lot that technology hasn't advanced and some in one breath, I hear people say technology has advanced incredibly. And then another routes I hear people say, we've been doing the same thing for 40 years.

And so when something is reduced to one sentence, it can become a platitude that could be used for, to support one point or another. Right. You don't actually know what it means until, until you describe it. But I do hear people say it on the side of technology has not advanced. And you feel like, it doesn't have where else is it going to go?

And you said like it's advancing a ton and so can you talk a little bit. 

[00:30:09] Dr. Carol Curchoe: So I think one of the things is like in the early days of IVF, right, we didn't know how to make cultural media. We didn't know humongous things. We didn't know how to incubate embryos. There were these like really big buckets that got figured out early.

And since then, it's been a process of refining all of these steps and there have been huge step changes in the field of IVF where seemingly everything changed overnight. I mean, of course that that's not actually how it went. It was a lot of small discoveries and small labs putting it into practice and people slowly doing it.

And then it seemed like the industry changed overnight. So the couple of things I can think of where that happened, where cultured a blastocyst which is sort of it's been adopted, I think by most IVF labs. Now you might still get ahold out few hold outs here and there that are only culturing to day three. 

[00:31:07] Griffin Jones: Seems like everybody is doing that so.

[00:31:07] Dr. Carol Curchoe: Everyone's doing, yeah, they, at least they have five, six, and now the newest thing is day seven embryo culture. So that has been hotly debated. And it's been, the body of literature has been growing over the past five years to other day seven culture is valuable for patients. I think now we're all starting to agree that it is, you can get normal embryos that implant on day seven.

And so that is a change that like when you talk about experimenting directly on people with no oversight, Right. The decision to go from culturing today, six to extending the culture one more day to day seven, that's kind of an easier decision to make. And there are a lot of things like that that have happened in the IVF lab.

So for example, one of the things that I can think of is the decision of when to hatch an embryo. We're getting all kinds of new technologies like Embryoscope and single-step media, and we're taking the embryos added incubator much less. And so people are starting to get rid of hatching on day three, which was kind of the industry standard for the last however many years since we stopped doing biopsy on day three and shifted it to day five and the wind started hatching on day three and doing biopsy on day five.

But what we've seen with success rates for embryos that are fully hatched is that by and large. They're a little bit lower than embryos that are frozen with Arizona. And so what people have started to do is leave the embryo totally alone and hatchet on day five when they do the biopsy. And so that entails them actually breaching the zona with the whole biopsy pipette and pulling the embryo across to the opening that you've made.

And none of those interventions are, have been properly tested. Right. We just decided to start doing that with patient embryos. And so we have no idea what the effect of tugging on the embryo that much or creating a larger hole in the zona is. But I think everybody sort of agrees that. We want there to be less fully hatched embryos on day six.

And the way to do that is not to hatch it on day three. When you make a hatch on day three, the embryo likes to grow out of that and it fully hatch out by day six. So maybe by doing that overall, we can increase the efficiency rates of IVF by five or 10%. If the whole field stops doing hatching on day three and starts doing it at the time of the biopsy.

And so IVF success rates are pretty good, , and then if we. Increasing them slowly by five or 10% through the use of these kind of lab developed techniques that spread from lab to lab. It's very hard to do any kind of a control trial for these lab developed techniques, any sort of a randomization or a control trial.

So RCTs in the US are extremely expensive. And so being able to test whether this intervention is more effective or less effective, it's very, very difficult. And so I think also one of the best tools we have at our disposal are these longitudinal databases, like the SART CORSdatabase. So everybody loves to hate on the SART CORSdatabase, but it actually acts as a very good post-market surveillance tool for the entire industry.

For these interventions that are, we can kind of point to a time period and say, okay, around this time, almost everybody adopted blastocyst culture around this time, almost everybody started hatching on day three for PGT. And so in a much larger sense, larger than any clinical trial could ever give us.

We can sort of monitor the success of the industry through these longitudinal databases. 

[00:35:17] Griffin Jones: And so this is about the growth of the umbrella, right? So it's not like I'm trying to think of how you would do an RCT like this and you wouldn't. I was thinking, well, this could be something for like this could be something that you use with embryos that you're going to discard, but we're talking about making the umbrella.

So that's not an option. And so what, what needs to happen in order for this to be something that can be standardized across the field. 

[00:35:44] Dr. Carol Curchoe: Yeah. So I think that's why there, there is no mechanism like that that exists. The CLIA regulations basically give us leeway to make and validate a lab developed test in our own labs.

So we will verify and validate that the test is working. And we do that in kind of a step wise procedure, but then what happens is we publish those results at a scientific meeting. And then the lab next to us says, I also want to implement this lab developed test or procedure in my lab. And so then they also go through a process of verifying it and validating it in their own lab.

And so there's a whole bunch of other different innovations that I can think of that fall under that category. Like everybody's doing the flick biopsy now. And that's a method of breaking the cells off of the embryo that obviously can't go through a randomized clinical trial.

There are ultra fast ultra fast thought and freezing protocols that are being developed. And we saw a jaw dropping talk at the recent PCRs meeting about an ultra fast thought protocol that had been developed in a lab. And I personally know, 10 embryologists who are going back to their own lab and trying to verify that work. And then way that the presenter presented it. And so yeah, I think that lake basically, embryo hatching, embryo biopsy technique, even the ICSI needle technique, itself. Has gone through some evolution. So there are some people who insert the ICSI needle and pierce the Oolemma very slowly and very carefully. And there are some people who scrape the Oolemma and stretch it until it breaks.

And then most recently I saw a pipette that sort of sucks back on the Oolemma membrane and makes it taut so that when you puncture it, there's no invagination of the Oolemma into the OS site. And so if you think about what's happening inside the egg, the egg has a cytoskeleton and a structure of its own. And when we pierce it with the ICSI needle and suck the cytoplasm out, we are doing some disruption of the egg membrane and the cytoplasm and the cytoskeletal structure inside the egg.

And so, again, those are all things that are very difficult to do any kind of an RCT on and where we always have to be asking ourselves the question, is our intervention helping? Or is it harming? Is it causing it? 

[00:38:20] Griffin Jones: And we don't know the answer to that is what you're saying right now. We don't know the answer to how much, that you're saying, if it is damaging, we don't know how much it is.

And so that's why we need the artificial intelligence for, to collect all of the data points 

[00:38:36] Dr. Carol Curchoe: And so many other things too, right? Like that just the existence of these longitudinal databases themselves are very important for the industry. But yeah, AI analysis of all of that data especially because humans, aren't very good at synthesizing large amounts of data and analyzing it.

Computers are better suited to that task than we are. So just giving, like tons of parameters different things that you think may or may not be helping or impacting, or even having a negative effect on an IVF cycle, right? AI, a computers are going to do that much better, but getting the data into a database where it's usable and accessible is the most important part of that.

So how do you collect all this data and not rely on people to do it? 

[00:39:25] Griffin Jones: Yeah. What will the role of experiments be, once we have data points for everything? I wonder about that. Like, when you have an artificial intelligence, when, when you have data points for everything, and eventually we will, as you, every breath that we take, everything that we purchase, everything we've made will, will be tracked.

And so what is the role of experiments once you have every possible variable accountable, because the entire point of an experiment is to control for variables. Right and so. 

[00:39:58] Dr. Carol Curchoe: Yeah and really defends the hypothesis, right. 

[00:40:02] Griffin Jones: But do you need the experiment to test the hypothesis if you have every data point from forever?

[00:40:08] Dr. Carol Curchoe: Yeah. 

Yeah. You definitely do. Because the, what you can do is, you can make a prediction. Based on all of those data points. So for example, what is your genetic background? Where did your grandparents grow up? Did they go through a famine and the country that they were living in before they migrated to the U S has there been, incredible stress in your life?

Are the sensors outside at your street light detecting a lot of pollution? Like you live in a heavily polluted area with a lot of car traffic. And so we're using environmental sensors in, in a much broader sense. But the role of experimentation, I think, after you collect all that data and have a data point for everything is then you're constantly testing interventions.

So by intervention, I mean, for example, like a treatment, a drug for endometriosis, for PCOS, for, let's say you have childhood cancers. And so there are different treatments that are impacting fertility later on down the line. There are a lot of STDs that directly cause infertility or STI that directly cause infertility.

So being able to intervene on these different aspects in a much larger way could be very helpful for people. It could be helpful to direct policy can be helpful to direct like public health policy, basically. But yeah, I think the role of experimentation will always be relevant. We're never going to solve all these problems.

[00:41:47] Griffin Jones: Okay, where does our compass figure into this IVF superhighway? 

[00:41:57] Dr. Carol Curchoe: Yeah. So we are just basically a new way to have a database that structures data in order for artificial intelligence to interact with it. So we're just a new way of, of storing and accessing data for AI systems and then providing the forward-looking statement on this, right?

All the AI technologies are in development. The first step is collecting the data. The second step is creating the AI validating it. So developing it, validating it, and then actually making predictions or prognosis. The low-hanging fruit we like to say is whether an embryo is viable or not. So just using embryo images instead of performing an invasive perfected or biopsy, and then waiting two to three weeks for the genetic testing results to come back, we could look at an embryo image and give a score right away for whether that embryo will be viable or not.

So those kinds of advances will be very good for patients. They'll cut down on like an entire cycle time between the time of the retrieval. And then the time you get the genetic testing results back and prepare the uterus for transfer of one of those embryos, it'll also be really good for patients because I think we are going to sort of solve one of the dilemmas of PGTA, which is that.

It really decreases the number of embryos that are available for transfer. And we probably are discarding some embryos that would have been viable. So patients are probably going to get more embryos in the end, more chances to try with those embryos that they've made. And yeah, so it's eventually it becomes diagnosis, prognosis and making predictions.

So business intelligence, even for running your clinic. 

[00:43:50] Griffin Jones: Do you want to share a little bit of what your abstract was about at PCRs because that I've found so interesting of that, of talking about of grading embryologists or their responses. Do you want to talk a little bit about that? 

[00:44:05] Dr. Carol Curchoe: Yeah. 

So if you ask 10 different embryologists ,the same question. You're probably going to get it back. At least 60% of the responses will vary. So a lot of what we do in embryology is, is very subjective. And it's based on your experience and what you have seen. It's not objective and it can be a challenge because so many other things are based on what the embryologist looks at and sees in the dish.

And then what they say about those embryos. So whether an embryo gets biopsied that day, whether it gets frozen that day, whether it gets frozen in the cycle at all of those things have an impact on the number of blastocysts that the patient has at the end of an IVF cycle. And so for embryologist, we need to be really consistent in our judgment and our grading of the embryos.

And it's just, the variability is just completely wild. And so the abstract that I presented at PCRs we basically just did a small survey to see whether the terminology that embryologists were using for early blastocyst development was consistent. It wasn't, and whether we could kind of trick embryologist into picking a fake term, that's not actually in use.

And that term was picked many times. 

So it just.

[00:45:33] Griffin Jones: What was it again? I don't remember the name of it.

[00:45:36] Dr. Carol Curchoe: It was cleaving morchella which is not a real embryo grade. And so it was just kind of interesting, but we've had a couple of surveys that we've published at ASRM and ESHREand shows what we know all along that the consistency and objectivity of embryologist is low.

I mean, we are human. It could vary depending on whether you've just eaten lunch or whether you've already graded 10 patients before this patient. And you're running out of time to do your body. I've seen freezing for the day. And so just being able to rely more on computers, to take some of that routine, manual subjective and highly variable labor off of our plates is probably a good idea.

[00:46:21] Griffin Jones: So once we do, then what is the embryologist going to do once that is off the plates? What are they going to do? 

[00:46:28] Dr. Carol Curchoe: The important work, right? Making sure the embryos get frozen correctly and that your patient doesn't end up having a boy when they asked for a girl, which was a news article that just came out last week.

There is so much more that embryologists needed to do. And some of the most important work that often gets, not a lot of time for is the quality assurance and the training of the next generation of embryologists. So just being able to invest more, even in the, the people and their techniques and it's there's plenty of work to be done outside of embryo grading.

[00:47:08] Griffin Jones: So before we close, I want to go on a little bit of a tangential topic, but it's related to how we opened the show, which is about the soon to be mass Exodus of senior embryologist and HCLDs is, and how there are fewer HCLD candidates in the pipeline right now. And this is totally anecdotal, Carol, but I wonder if you're seeing it too, is I'm seeing a lot of younger embryologists trying to get the hell out of the lab at a time were they've never been more desired. They've never been more in demand. And like everybody's trying to get their hands on embryologists and, and I'm seeing, so I've got a couple open positions for my business development and creative firm, nothing to do with the lab. And embryologists are applying for jobs at my firm.

I get at least once a week, at least one a week, and then I'll talk to them and it typically comes down to, they don't physically want to be in the lab all day. They hate that. And then they don't like the burning the midnight oil been burning the midnight hour, that whatever hours. Yeah.

And so I don't have any data on younger people trying to get out of the lab, but Canary in the coal mine. That's what I'm seeing. What do you see? 

[00:48:31] Dr. Carol Curchoe: Yeah. 

So I can think of that is partially accurate there the profession itself is very difficult. A lot of times so you have a very high pressure situation where you can't make any mistakes.

 It's highly likely that the other people you work with in lab have a certain amount of a certain level of OCD, and that they're going to be correcting you nonstop all the time for your first five years until you become a senior embryologist. Even among senior embryologist, they're going to be correcting each other and picking out each other all day to do things the right way and to document all of these little small details.

And you have high pressure situation long work hours, a lot of times weekends and holidays are required. Because the IVF lab they say it can never stop. And so a lot of those things are management decisions that what it comes down to is you are choosing to run this many cycles with this number of staff and have your clinic be open on all these days and to do retrievals every day of the week.

And on holidays, you could choose a different way to manage your practice. But what I think is the most compelling part is we have to get to an agreement where the number of cycles can scale and really treat the number of patients that need IVF in the country, which we're only treating a fraction of, but that the management of the cycles within the clinic has to somehow get more better for people, more family friendly, more friendly for the embryologists. And so again, I think a lot of that is going to have to do with technology. A lot of healthcare burnout comes from continuous documentation of, of items is that you don't even know why are we doing this?

It has no, it's never going to have any impact on any cycle. It just gets filed away in a binder and put it in the closet for the next 10 years. And so there are just, I think there are just different things that every step of the way that kind of need to be looked at. I also think training more male embryologists in the field would be very helpful.

But I think what happens now is, is maybe a lot of male embryologists start off in embryology. And then they're like, I'm not going to take this. I'm going to go find a better job for better pay and less stress. And I think if we were to do that and get more male embryologists, maybe that can help to actually raise the standard for all embryologists.

And it could also smooth out some of those real big dips that happen when with a lot of maternity leaves and different things that happen in different practices. But for the female embryologist, I know many of them have been asked to return to work within four weeks of having their baby or less, because they're the only embryologist who knows what they're doing in the lab or in that area and. 

[00:51:52] Griffin Jones: Technology is really, it has to be a part of it though, because right now we're in a chicken and egg, and this is all across the marketplace. It's not just the fertility field. It's not just an IVF lab. It's happening everywhere. That tension I'm talking about is between employee needs, wants customer needs wants.

And in our case, staff member, provider embryologist needs wants versus the patient needs, want, patients wanting to get pregnant and they want to be seen, and they don't want to wait eight and a half weeks, 10 weeks, 12 weeks for any IVF cycle. And so I can empathize with both sides here, which is like, we're trying to help these patients here.

And so we're trying to put more people through on the other hand, we're burning people out and then, so they're quitting and then that puts the, makes the burden even heavier for those that remain. And so. We have to have technology. We have to adapt what ever technology that we can to be able to reduce this burden, because otherwise we're just going to be stuck on until, until some other economic force, like a recession or something comes in and makes one side of the teeter-totter go up in one go down.

But until that happens, like we're all. And even then it will be temporary. Like we need this technology in order to break that chicken in the egg. 

[00:53:21] Dr. Carol Curchoe: Yeah, 

absolutely. And I just think, we need to responsibly scale cycles so that it, so that it doesn't break the backs of the workers, but it also, we scale the industry to serve as many patients as possible because people really need this life altering life saving, really technology that we have that.

We need to be able to make it available to everyone who needs it. 

[00:53:46] Griffin Jones: I'm going to selfishly give a little plug for something that I want to see., and then I want you to conclude with the way that you want to conclude. But what I selfishly want to see is a story to tell the importance of the different parts of the lab and the, and the clinic like meet like the hero's journey of the embryologist, the hero's journey of the fertility nurse, because everybody's going through burnout.

People like yourself and others are doing what they can to bring technological solutions as quickly as possible. In the meantime, for being able to carry the burden, it really helps to know to tie into. This greater purpose, this story that you see, or this drama playing out that you see yourself as a part of and creative really helps to do that.

So when I came into the field seven or eight years ago, Carol, it was about new patient acquisition. That was my value prop. And then for a few years, it's still was that most clinics don't need that right now don't need new patients, a couple profiles do then there, it was about converting more to treatment of, okay, you're bringing enough new patients in the door, but you need to help converting them to treatment.

Even now, most people are like, well, it doesn't matter if we convert more because we're at capacity at the lab. And so what we're trying to use creative for is like, use it in such a way that get your people and your patients to be able to understand go through and be a part of like, what's really important for getting this done on the patient side.

It's very often about resetting expectations and on the staff side, nurses, embryologist, it's about seeing like how like really important this is. And you might, you might say like, oh, well, like of course we see it. We see it every day because we're living it. No, there's something about the story allows you to see how you play into it.

I used to volunteer at an orphanage of, of a network of orphanages called new Esther spontaneous or miles. And I was there and I did it like every, I lived there. I did it every day. I'm telling you Carol, that when I watched the YouTube videos of like, of like the family at large and would see like how we played into the bigger.

I was like, yes, this is what I'm doing it for. So I want to see that. I want to see it for the embryologist. I want to see it for fertility nurses. And there's so many different ways to tell this story. And if you're listening, talk to me about that because I'm not talking about just getting new patients in the door, I'm talking about, about using creative to solve challenges, like best, but I'm going to let you conclude that was, that was selfishly for what I want to see.

What do you want to see happen in the field? How would you like to conclude with our audience about the future of, of the lab as you see it? 

[00:56:55] Dr. Carol Curchoe: Yeah, so I think we need funding to make these innovations happen. So I'm in a very small group. A very small segment of the population who ever becomes an embryologist and then creates a technology and makes a startup.

I'm a female founder. And I didn't go to Stanford. I don't have a pedigree. And so the funding, I think for a person like me and the avenues to funding are it's extremely difficult, less than 2% of all female founders nationwide ever get funded. Right? So its ambition, a small market, and we need just more funding.

I know everyone's talking about fem tech nowadays and getting more funding into these technologies. And so that's great. I think that that just needs to go rise more and more and more, but if you're an average everyday embryologist and you have a good idea that needs to be commercialized, and you're the one who's working with these technologies every day and what could make your life better and easier?

How would you commercialize? How would you even go about how would you, what would be your first step to commercialize the technology? And I think it's just not talked about a lot ever. And so having just like the education, the startup education and the mindset of being able to drop a blueprint with an engineer, get a patent together try to raise funding and build a company.

 How to do that should be a little bit clearer and a little bit easier for people to do so that we can continue to innovate basically 

[00:58:44] Griffin Jones: Dr. Carol Curchoe of art compass and CCRM Orange County. Thank you so much for coming onto the show. 

[00:58:51] Dr. Carol Curchoe: Thanks for having me.

137: Private Equity: Genghis Khan of the Fertility World? with Laura Olson

This week, Griffin speaks with Laura Olson, long-time political science professor at Lehigh University and author, about what private equity has done to other healthcare sectors, and what Olson believes it has the potential to do to the fertility space. Should it be banned, or is it the key to correcting the supply vs. demand struggle in fertility care accessibility.

Listen to the full episode to hear:.

• Laura Olson’s take on the private equity playbook.

• How private equity has negatively impacted other areas of healthcare, and what that might mean for fertility care’s future.

• Why new docs and retiring docs make the decision to get into bed with private equity- or not.

• Griffin push back on the lack of data to praise or condemn private equity controlled networks 

Laura Olson’s Information: 

Linkedin: https://www.linkedin.com/in/laura-katz-olson-a7706034/

Website: https://wordpress.lehigh.edu/ethicallychallenged

---

Transcript

[00:01:01] Griffin Jones: Which side are you on which side are you on in private equity and healthcare, or I don't know. That's why I keep having guests on either side of the position on the show today. I have an author for you. I brought an author named Dr. Laura Katz Olson. She is a professor of political science at Lehigh university.

She's been there since 1974, and she has a book called “Ethically Challenged; Private Equity Storms US Healthcare”. And she, even at the end of the show, she mentioned, and she says, it sounds like you're not sure. Well, you probably heard me say that on the show of what is the categorical net benefit of outside money in our field buying practices.

And I have people from different perspectives on the show. I don't know guys, like I told you, I'm a communication. Major bachelor graduate from Oswego, NY in upstate New York. I'm not the scientist, but I do appreciate scientific thinking and what I'm still lacking. What I still haven't gotten from other side is.

Really good data to help me say what I think is category categorically better or categorically worse one. I don't even totally know which metric that I would judge on. Would it be patient satisfaction? Would it be clinical success rates? Even if it were like how many other variables take that.

But I suspect you'd probably have three to six key performance indicators. Right? Because if you just had one, you can always maximize one outcome and it could be at the detriment of other things. So you'd probably want various KPIs to balance each other out to say, okay, is this, is this having a net benefit or a net negative?

And I haven't heard that yet. So I asked a little bit for it in the. Interview, it may be in the book and I still haven't gotten my copy yet, so I hope to be able to dig more in but I haven't totally heard it from the, the network groups either. I just hear a bunch of case studies on either side and I seek case studies on either side  manifesting themselves in real life of-this is an example where we've improved efficiency and raise the standard of care.

This is an example where we're reducing costs and reduce the standard of care. And so I would love to hear about how we would really measure this. If we're seeking the truth, I'm seeking the truth guys. I own a privately held business development and creative firm. That's my normal pay grade. And I'm punching up to give you more education and information, as it relates to building your businesses, starting your careers, advancing in your careers. And I would love your thoughts on how we would pursue private equity and venture capital who have both very different impact in healthcare, specifically the fertility field.

But today, I let Dr. Olson give her perspective. She wrote a book about it. She feels very strongly about it, and she does have really good examples to include in her arguments. So you let me know which side do you fall on this, but in the meantime, enjoy today's Inside Reproductive Health with Dr. Laura Katz Olson.

Dr. Olson, Laura, welcome to Inside Reproductive Health. 

[00:04:24] Dr. Laura Olson: My pleasure to be here.

[00:04:26] Griffin Jones: You are coming from an area that is a little bit broader than just reproductive health, justice assisted reproductive technology.

You've recently written a book about private equity in healthcare, and it's called ethically challenged. So there might be an angle where we're pursuing in today's combo is it's called “Ethically Challenged: Private Equity Storms US Healthcare.” Why this book Laura? 

[00:04:52] Dr. Laura Olson: Well, I've been studying actually aging and healthcare now for about 50 years.

And private equity just kept cropping up by when I was looking at nursing homes on healthcare. But I couldn't find anything about it. And then when I was looking at comparisons between let's say, a home health care that's commercially owned and those that are non-profit, they never differentiate the commercially owned from regular commercial to private equity.

And I found that very strange. So I started looking into it. I went to a private equity and one of the reasons I've discovered is because of the secrecy. They, private equity firms have what they call a pension for secrecy. I bought a private equity data from PitchBook, which cost I had a razor for my university, but a plus 22 thousand dollarspacks a year.

And I went to a couple of private equity conferences. One of the incidences that I discovered, which was really a kind of interesting is there were about 350 people at this conference, one of them, and at every session they reminded us that everything that went on there was confidential. And of course, as my father once taught me when I was a young girl and more than one people, one person knows about something it's not confidential.

So the secrecy thing really got to me and got me really more and more curious, and I dug deeper and deeper into how it affected health care and eventually decided this is a story that has to be told. 

[00:06:33] Griffin Jones: So, when did you start noticing it? You said you started noticing it in senior care and other areas of medicine more or less.

What ballpark of years did you start seeing this trend happen? 

[00:06:46] Dr. Laura Olson: I started noticing it in the late 1990s with nursing homes. And then it kept cropping up later on, I would say, oh, about 20 10, 20, 15, a lot of the niches, especially fertility didn't really take off, take off until about 2015.

 So the earliest ones that I noticed were the nursing homes and then more and more of the niches, it started coming. 

[00:07:19] Griffin Jones: Okay. Do you have any idea why that 2015 mark is, is happens to be that because we've noticed that in fertility, that it was about 2015, it wasn't to say that there was no one before 2015, but really that's when you started seeing.

[00:07:36] Dr. Laura Olson: I think that was the first 1, 20 15, if I'm correct. 

[00:07:39] Griffin Jones: Well, so there was IntegraMed , which had gone public and they did own equity of practices and they were, they were early. My listeners will correct me, but I want to say that started in the late nineties. And then they went public at some point in the two thousands, if I'm correct, when my timeline and then were bought off of the market listings by a private equity firm called Sagar Holdings.

But, and that may have been in 2012, I'm making up the year. So I'm hoping one of my, at least one of my listeners will send me an email and, and correct me on it but. 

[00:08:14] Dr. Laura Olson: So Ovation Fertility was clearly one of the first in 2015, which was bought by Windrose. 

[00:08:22] Griffin Jones: And so why is that? Does your book uncover some of this of why halfway through the last decade, did we start seeing this in our niche and others?

[00:08:32] Dr. Laura Olson: Well, I think that there's a number of reasons. And each niche really has its own reasons. There's a general number of reasons that a private equity firm would be interested in a sector. And as these reasons come to the forefront, the private equity go into, for example with fertility, which obviously came later than some of the others.

You get the idea that there's more and more children, people are having babies later. So there's more need for fertility treatment. You have about 15 states now mandate that insurance companies include fertility in their package of offerings more employers are offering a fertility treatment.

The veterans administration now pays for fertility treatments and it's big money. One of the things that I found that was interesting is I spoke to a number of owners of fertility, people who sold to well private equity. They were the most generous with their willingness to talk to me, fertility treatment the owners was interesting. 

[00:09:47] Griffin Jones: On or off the record? 

[00:09:49] Dr. Laura Olson: On the record. And I had the trouble getting anybody else to do them, but they seem to be the most willing. 

[00:09:55] Griffin Jones: What did they tell you? 

[00:09:56] Dr. Laura Olson: Well, let me just give some of the reasons, you have rising single parenthood, but even more important. That I think is we should know is that there's a growing amount of dry powder in private equity.

What that means is they have more and more money this year. They made a record in 2021, a record of something like $330 billion. And they have to spend it somewhere. 

[00:10:23] Griffin Jones: This is just in healthcare is private equity healthcare who made. 

[00:10:26] Dr. Laura Olson: No, this is just private equity money to spend, to buy, buyout funds, to buy.

And they're running out of Toys R Us places, retail places, and they had to find something and healthcare, but particularly fertility care is very lucrative. One of the people I talked to told me that after they put it together and they were ready to sell. He got offers from 40 private equity firms.

So fertility is a hot market right now. 

[00:11:00] Griffin Jones: That makes sense to me. And 40 of those 40 it's like how many of them were good, but sure I bet, people are kicking tires all the time. Some to often people think, oh, I got a call from such and such a firm. Maybe I got a call from Canar or somebody.

And it's often a junior account executive whose job it is just to touch up with everybody and keep your name accurate and in the file. But sure, there are also a number of people that are already within fertility networks that, that are a part of this. So I'm writing down my questions that I have for you, as you say, things that I want to go deeper into, one of which was the $300 billion. And you said that that's a record that was a record in 2021 that private equity firms have to spend. Do we have it? I suspect some of that is just because when inflation goes up, stop people, buy stocks and equities. And so high net worth individuals are putting more of their money into behind these private equity firms.

But did you, do you have any more of the research of where the money is coming from causing the surge? 

[00:12:06] Dr. Laura Olson: No a huge, huge percentage of the funding for private equity acquisitions comes from pension funds. It comes from a state and local pension funds and they of course have been underfunded for decades.

And so they see private equity is a way to get a quick book and make up for the. Pension deficiencies. So most items have the statistics right in front of me, but most of them have increased their private equity investments 2% over the last several years. And they intend to increase it even more, so more and more of their money is not going into the stock market, but it's going into private equity, even though private equity is risky.

[00:12:58] Griffin Jones: Why did you say that? 

[00:13:00] Dr. Laura Olson: Well, that's why they have to make outsize profits because the money you put into, first of all, they keep him money for a long period of time. It's not liquid. And you can go bankrupt. There's all kinds of risk in private equity that you don't. That's a, of course you have risk in the stock market, but that's a far less.

[00:13:21] Griffin Jones: It's not the S and P 500 that's for you. You're not looking for an average 8% return. 

[00:13:27] Dr. Laura Olson: No, you're looking for what they call outsized profits. And they don't really care what they invest in. They can invest in hospice. They can invest in infertility. They can invest in Roto-Rooter. It doesn't matter to them.

They're only like Willie Sutton looking for where the money is, you know, who Willie Sutton is right. 

[00:13:50] Griffin Jones: You're going to have to refresh me. 

[00:13:52] Dr. Laura Olson: He's a bank robber. And when they asked Willie Sutton boy, he robbed banks, he said. 

[00:13:59] Griffin Jones: Oh, that's where the money is. 

[00:14:00] Dr. Laura Olson: That is where the money is. 

[00:14:01] Griffin Jones: So that's who gets that quote. I should know that I really liked field.

I don't know if it was he the Deringer, Bonnie and Clyde era or prior to that. 

[00:14:09] Dr. Laura Olson: Probably around there. I think it's later. 

[00:14:12] Griffin Jones: Well, I'll have to watch something on him and Babyface Nelson and the others and get reacquainted with my old timey bank robbers sounds like a good theme for the show, but so you're talking to fertility practice owners as you're writing the book.

And I'm curious did anything stand out to you as being distinct within the fertility and within the field of fertility? You mentioned that it was a private equity firms are seeking outside profits. They could be talking to plumbers. They can be talking to electricians and, or dry cleaners or anyone and they do.

But did anything stick out to you as different?? What's happening in the fertility field then in other areas or even other areas healthcare? 

[00:14:56] Dr. Laura Olson: Actually, the private equity playbook is pretty static. And one of the differences I think with fertility is that it's new. And as with all the new niches, the relatively the argument that I hear from a lot of physicians and a lot of people in the government and and so on is it's too early to tell.

And if you understand the private equity playbook, and if you understand the history, it's inevitable that certain issues and problems are gonna come up. As far as I can tell, you have to be a magician. I don't know how much your listeners know anything about the private equity playbook. 

[00:15:44] Griffin Jones: Tell us a little bit.

[00:15:45] Dr. Laura Olson: Okay. The private equity playbook begins with the idea that you have to get outsized profits. And again, you can't just make ordinary profits. Well, people will put the money in the stock market, so you really have to give them a lot more than that. They take these profits and buy a flourishing company.

Let's say a flourishing fertility company. They don't want a distressed company. They want something, one that's really well-established and one that's doing really well. And the reason is because they're buying the company with borrowed money today over 60% of all the money is borrowed. Your private equity firm puts in about 2% in equity and they're limited partners.

Usually the pension funds put in about 38%. So you have to pay off this debt. And in addition to the debt, you have to pay off enormous fees. For example, they have transaction fees, monitoring fees, management fees, advisory fees, servicing fees. And I just discovered the other day, there's an other, that's now becoming very contentious and that's the food and travel of the PE manages.

Then you have the dividend recaps, which is where the private equity firm borrows more money from the lays, the debt on the company and pockets it. And these are being bought with what they call junk funds, junk rated loans.

And this has increased enormously this year, also that at 330 billion. So they're pocketing more and more of this money. So what I say, you need enormous cash flow to pay off this debt, to pay these fees, to pay these dividend recaps. And how do you get enormous revenue increased revenue. And that has to come from the operating costs and shrinking operating costs.

And I have an analogy. I see the private equity firms, like the old time doctors in the 18 hundreds. Remember they used to bleed patients and the patient either got really weak or died and that's what they do. And they used to use the 18 hundreds. Sometimes they use leeches, which I think is an ophthalmology for the private equity firm.

So the way I see it, you have to be a magician to be able to pay off all those debts, pay off all those views and keep quality of care. So that's the general outline of private equity and healthcare. 

[00:18:44] Griffin Jones: So you mentioned that part of the private equity playbook is buying a flourishing company.

And very often when we see a new network coming to the field, usually they're starting with, they're saying, can I grab at least one big center, , a group that has. At least 10 docs and is in a pretty sizable market and then use that to use them as the flagship of the new partnership or network.

And and then use that to be able to court other perspective practices to, to sell into my network. So when you say buying a flourishing company, is it, is it, is it that is it just for that, that flagship group or. And then the rest of the portfolio, they're okay with having a distressed asset in here or there, if they can get a good deal on it, or these are all really, really profitable companies that they generally want.

[00:19:36] Dr. Laura Olson: Well, in healthcare, in the old days, they used to buy a conglomerates and then break them up and sell them because the parts were worth more than the hole now with healthcare and fertility centers, but other health care what they do is they buy this platform that you were talking about, but then they add onto it because the idea is to get a local, a regional, or even a national monopoly.

And then they only have four or five years and they have to sell. They generally don't keep it more than four or five years. And it seems to me that it's been lowering the average today is four point, I think it's 4.5 years, but many of them are being flipped in two years. So three years, and then the next private equity adds more and makes bigger.

And so what this does is it makes one prices higher for treatments because they're the only game in town. Once they get a monopoly and choice for consumers is far less. So it has that effect as well. 

[00:20:40] Griffin Jones: So why then are we still seeing more new network backed private equity firms come in as opposed to the current ones being able to consolidate more?

So if everybody has, if they're on this timeline of three to five years, we're still seeing, I think now this. Six to 12 months, we saw three new networks come into the field and there's already a handful here. Then each of those networks are backed by different private equity firms. And so what's going on with this timeline?

Why aren't we starting to see some of the folks that have been around since 2015 or 2017 sell? Well, I guess we have, we have somewhat but why wouldn't you, why wouldn't these new private equity firms be trying to like buy into these firms, buy into these networks or these networks trying to, why haven't they been successful in gobbling up the clinics that these new networks who who've only been here a year or less have been able to do?

[00:21:44] Dr. Laura Olson: I'm not sure they're not successful. I mean, it takes time. And we're talking about very recently. So what would I see for the future is these new networks, increasing in different areas, like, immediate immediately jumped to a national, a monopoly. They spot in cities, they start in different cities.

So you'll have one start. I don't know about, about fertility, but I have seen the history of these. They start in a certain area in Florida or a certain area in Kansas and they slowly build themselves up until four or five years and they sell and then the next one comes in and build itself up. So you have simultaneous in hospice and home care and all these other natures, you have simultaneous platforms building each other up, building up.

They're usually from what I can remember, they usually start in different areas. Somewhere in the south may aim for the south. Some in the Northeast, they aim for them with these. They don't immediately jump in volume, like every year they might buy three and they have to integrate them, which is, which is a big problem.

[00:22:57] Griffin Jones: The integration is a big problem and we can probably, I'm making a note of that. So we can talk a little bit about that. As far as the timeline goes, are there other categories that are more mature? You said that in a lot of the niches that started in 2015 or so, and as you mentioned, relative to other fields of healthcare and other fields of business, fertility is still pretty new. Are there other areas, especially areas of healthcare that are more mature where we've seen it become a, a two horse race or, two companies control everything and other areas of, of healthcare. What's that like in more mature sub-segments? 

[00:23:36] Dr. Laura Olson: Scene where it's become a two person race. But certainly you have one of the early ones is dermatology.

And you see a number of the dermatology companies that have grown and is still throwing themselves off to the next one and not, and not looking to become they're not like a regular corporation. They're only looking to build the value for four or five years, and then they take their money and they run and they either put it up for an IPO.

But more likely these days they're selling to each other. So it's very different than a corporation. So you don't see two major corporations running against each other, but dentistry has had a long history. Dermatology has had a long history. Ophthalmology has had a relatively long history. And what we see is disaster both in terms of the patient care, the quality of care and in terms of bankruptcy.

[00:24:46] Griffin Jones: So I want to talk about the bankruptcy part because that's less self-evident. If, if people are continuing to come in and. why are they doing that? If they're risking being the one, holding the hot potato at the end, and I don't know enough about the IntegreMed deal, but it could have been the case.

That's the guard was holding the hot potato at that point that they had something that they were losing money. And then whoever bought what those properties came into, perhaps got got a better deal on it. But so if it's leading to bankruptcy, what is the incentive for firms to continue doing it?

 It's not my job to tell you what you should do. Should you sell the private equity? Should you fight as an independent practice owner and independent fertility business owner forever. That isn't my job. You started a business or a practice for your reasons. My job is to help you, get to where you want to go, whether it's selling to them or competing against them that's what my firm does. We help you pull out competitive advantages and we are not operations consultants. I will never promise you true operational efficiency as a deliverable. That's not us, but all of those areas where sales and marketing overlap with operations to help for a better patient experience.

Those are the things that we help with. So as you're recruiting staff and you're recruiting doctors and you need the messaging, the brand and the customer service systems that allow you to be relevant. That's what Fertility Bridge helps with. And the only thing that I really ever try to sell people is that initial diagnostic that we do because it's less than $600.

It's $597 to have a consult with us, to have my team do a snapshot and tell you what you need at a high level and go through that with you through the patient journey and then recap everything in a 30 minute follow up it's $597 to get you some of these answers that you're thinking about now, as you think about the future of your group at a high level, go to fertilitybridge.com, sign up for the gold diagnostic.

And I look forward to doing it with you.

 But so if it's leading to bankruptcy, what is the incentive for firms to continue doing it?

[00:27:06] Dr. Laura Olson: Well, a number of reasons, I'll just give you one example, and then I'll tell you some of the reasons U S dermatology partners, which is the third largest dermatology organization in the United States. And I remember when it first started and when I wrote my book, it was still going strong. And then I read in 2020, they defaulted on their loan and wanting to the third largest dermatology company in the country went into the hands of its creditors. So what I would argue is that it probably over stepped itself in terms of loans. if you very greedy, like Bain Capital was with Toys R Us they took dividend recap after dividend recap, and each time that they put these millions and millions into their pockets, they got loans and they can overstep in terms of they get just too many loans.

They can buy too many companies too fast. Which leads to, as you said, integration problems, but also they couldn't pay the loans that just too high. There's all kinds of reasons that at one point they may go into a default and bankruptcy. But one thing I want to make clear is that the private equity companies take out a lot of money before they go bankrupt.

And many of them lose nothing. They also don't have a lot at stake because they've only put 2% equity. So it's not like the private equity firms are going bankrupt. It's the company. 

[00:28:43] Griffin Jones: Well, the very least they have to make good for their LPs. Don't they, even if the firm itself put in a minimal amount, they have to, they have to at least cover their LPs.

[00:28:54] Dr. Laura Olson: Well, they don't have to make up for a bankruptcy, but you gotta be, they have about they have a fund. The LP are really putting money into this fund. Let's say fund number five, they number their funds and fund number five has 12 to 13 companies. And if one goes bankrupt, it doesn't mean that the LPs are losing money because the other 14 or 12 firms could be just doing fine.

I mean, the only real loss is to that one company, its workers and the communities in which they live. 

[00:29:33] Griffin Jones: Hence the risk.

[00:29:34] Dr. Laura Olson: I've never seen a private equity firm suffer because one of their firms went bankrupt 

[00:29:39] Griffin Jones: Do you have any data on the number of healthcare networks funded by private equity that have gone bankrupt between years, whatever, and between years three and 10 or whatever it might be? 

[00:29:57] Dr. Laura Olson: No, no I've seen some data. I just don't have it at hand. 

[00:30:01] Griffin Jones: Because I'm curious where I think we're all curious as to is that as to how frequently the IntegreMed situation happens.

And there is a intermediary here, which is the network themselves. Right. And so you have a US Dermatology Partners, I'm assuming was not the private equity firm. They were the operating network. Am I right in that? Sometimes they call themselves a partnership, but let's just use the word.

[00:30:27] Dr. Laura Olson: No, no, no. The US Dermatology Partners was the conglomerate or not the conglomerate, the platform and the ad-ons. And I forget how many locations they had something like 40, 50 locations and across 30 states, something like that. So the private equity firm was the owner of the whole.

[00:30:49] Griffin Jones: Sure. But where, and within the US Dermatology Partners where they were each of the practices called something different. Dr. Patel's dermatology here, San Diego Dermatology etc. 

[00:31:01] Dr. Laura Olson: Well, that's a very good question. I'm not sure for us dermatology, but a number of private equity firms that buy these companies and build them up into huge state or national monopolies, use something that one of my personally had interviewed, he calls it stealth branding.

What it means is that when you go to the company, it has John's Dermatology, as opposed to a US Partner's Dermatology. So you don't really know that you go into a private equity firm. So some of them do that. Some of them use the name of the US Dermatology and others. Each practice will have a different name.

[00:31:43] Griffin Jones: The reason that I ask is because in our field, we were still one degree removed from the actual private equity firm in many cases, which means that we're then two degrees at that position from of separation from the limited partner. So IntegraMed was the network. It was the conglomerate, as you say, and then behind them was the safeguard.

And that's the case for most of the networks are doing the purchasing. And so again, sometimes they call them partnerships, but then there's a private equity firm behind that funds that conglomerate to that, that network. And so and, and so I think an important distinction for people is that you still might want to find out who's behind those folks.

[00:32:26] Dr. Laura Olson: Yeah, but I want to, I'm going to make clear that regardless of what the private equity firms say, And the mantra to the doctors is that we're going to take the back office burdens off of you. We're going to let you practice medicine. We're going to do regardless. They get from control. All you have to do is look at the board of directors.

Talk to people, see what goes on, but they maintain from control. So the doctors can't just go out and buy anything. They want the fertility places that I write, talk to the owners who sold them, said this strict control. Even one who was, felt positive about it said, I can't just replace some material anymore.

I can't upgrade my equipment. We get rid of nurses and taken less trained people. We do less training all kinds of, I guess, less benefits to our personnel. There was like a list of, from the three or four people I spoke to of negative things that have happened, the patient care and the practice.

So it's not like it just goes on as if nothing had happened, they have to squeeze. 

[00:33:44] Griffin Jones: Well, then that brings us to the title of your book, which is which is ethically challenged. And so let's talk a little bit about this and then maybe I'll steal-man, their arguments at some points. But it seems like you feel that they're not creating the efficiency they have to squeeze. And so what are the ethical implement implications that led you to this conclusion that this is a. Ethically negative thing happening in healthcare? 

[00:34:11] Dr. Laura Olson: Well, because it's affecting quality of care. If you go through the niches where there's some sectors that have a longer history not fertility or some of the newer ones, but if you go through the LP dentistry, if you go through some of the others, there's a long, long history of private equity taking over companies.

And what you see is neglect, you see abuse you see poor quality care in 2012, the. The US Senate did a whole investigation on dentistry and they found that they were putting children on a, what they call papoose boards, so they could extract teeth and do things faster.

They found amazing amounts of abuse. Even today you'll get some, not even today. Yes. Including today you get places like Aspen dental which has a long, long history of abuse, poor treatments. If you look on the any kind of a place that shows what clients and staff think of these places, they'll get a one out of five and a whole bunch of really terrible criticism on.

And you get places like the what's the other one, I just picked out some forefront, dermatology, great expectations, which in 2019, the better business bureau said that they get an F in terms of quality of care. But you can go through all of them.

I picked out some from various niche. 

[00:35:39] Griffin Jones: Well, that's my concern, Laura, is that people are picking out on either side. And I want to know how do we measure these things categorically, because the private equity firms are picking out cases of look at this for this practice that they couldn't invest because the doctor was overworked and, and halfway out the door and didn't have an operations infrastructure.

Didn't have a business background, whatever it might've been. And I see poor rate ratings from, practices sometimes I also see really poor ratings from independently owned practices that talk about how they have such a good standard of care. I see both a lot. I see you're using the camp, the example of dental.

I think I went to, inspire dental, one of those similar ones. And I liked it. I go in, they all know my name. They have a great infrastructure. They've got a great booking system. Just hang my coat up. I'm not, I'm barely seen by the dentist. The dental hygienist does what a dentist is probably doing it.

Many other practices where the dentist comes in at the end and checks and say, okay, this is good. And it's a very easy experience for me. It's lower cost than, or at least equal cost is, is an independent dental firm. And so everyone's pointing including myself, which is why I can't make a categorical judgment on how positive or negative this is for the field.

Because people are pointing to these examples here and those examples there, how do we judge this? What measures can we use categorically across the board?

[00:37:06] Dr. Laura Olson: Well, first of all, I picked out cases because I couldn't go through all of them. It's not like I picked out the worst cases. I just picked out two out of a hundred kind of thing.

Second of all, yes, I agree with you. One of the reasons I studied nursing homes for many, many years, and one of the reasons I didn't put nursing homes in my book is because nursing homes tend to have very poor care. Every government study will tell you that to differentiate between private equity and normal profit-making companies is really difficult.

But I think when you look at some of these niches like dentistry and fertility well, not fertility. I mean, ones that have been there a long time and talk to experts in the field, they will say that this is not good before the healthcare system, because it has to affect negatively quality of care.

Now, I suspect that you have pretty good teeth.

[00:38:10] Griffin Jones: Invested a lot in those over the years, braces, twice surgery on my upper maxillary. 

[00:38:17] Dr. Laura Olson: But you haven't, experienced what happens if you have some real serious issue. Is that going to be done by a nurse practitioner or is it going to be done by a surgeon? I mean, and I don't want to comment on one place.

All I know is that if you truly understand the private equity playbook took me a long time to figure it out. If I truly understand it, it is impossible to have high quality. And take out all that money to pay off debt, all that money to pay private equity. Well, there's nothing left for quality care. And as I said, the few fertility doctors and people that I talked to pretty a scan at what has gone on in the few places that they have seen. 

[00:39:03] Griffin Jones: So you're making a case of why it has to be why it has to affect quality of care negatively because of the debt what's required to service the debt because of what's required to return the investment to the limited partners, especially if the, they went bankrupt on something else, then the burden of returning a multiple.

An outsized profit is even more necessary for the limited partners. So you're making a case of why this is part of inherent in the model. Why have they failed it at delivering on, on the economies of scale that they shoot, that they're promising in your view. And so if they're telling the doctors, look, you can just focus on medicine, let us take care of the EMR and the payroll and marketing and construction and everything else.

Why are they failing on delivering a benefit to economies of scale that as opposed to them just having to take out they're improving efficiencies. 

 Why have private equity firms failed to be able to deliver on the promise of improving economies of scale?

[00:40:07] Dr. Laura Olson: They can definitely do economies of scale. But the problem is that affects the quality of care. No, this is like, if you have, for example one of the fertility doctors that I talked to say that private equity owned places look to get more and more patients and they do it on an assembly line.

So they don't give the same kind of care to each patient. They just sort of go through them fast, that efficient, but that's not necessarily quality care. So efficiency and efficiency in retail may hurt. So the number of workers you may go into a store and somebody doesn't jump at you today.

You find what you're looking for? It's annoying, but in healthcare, efficiency can mean less care, faster care. And certainly less quality. 

[00:40:58] Griffin Jones: W w what if it means, , a center that has been on paper charts in, yes, there are still a couple that are on paper charts, even in the year 20, 22. And for whatever reason, they didn't switch to any, they didn't want to go through the costs.

They didn't want to, take team members off. And a network comes in and says, well, we have a, a cheaper per provider license or whatever per unit licenses is for the EMR. So we can introduce that, that economy of scale, we can bring in our team to train your team. So that won't be an additional expense.

Oh, you. You can't treat enough patients because you don't have any embryologists. We have a team of per diem embryologists, and we can send them to your clinic on the weeks where we're not batching at other or whatever it might be. Why does it, why does it always have to lead to a poor quality of care instead of in those examples, those are the arguments they make.

It seems to me like it would improve quality of care. 

[00:41:58] Dr. Laura Olson: Well, first of all, what I have seen in many of the niches is that they use lessquality materials. Many of the people I talked to said that they got rid of the regular suppliers and they get cheaper suppliers, but that has come with cheaper materials.

They stint on the use of materials, according to what I have heard they Don't train their people as much as they should. They often get rid of physicians to put in less trained physician extenders. If you look at dialysis, for example, model only is it egregious conditions in the owned by dialysis, but the studies show that more people die than anywhere in the world. In, in our dialysis centers they try to keep their patients rather than put them on a transplant list.

Studies have shown there's all kinds of things that they can do to affect the quality of care. Now they're not looking to have negative quality of care. They're just looking to squeeze operations. So they could have as much money coming out and they can hand themselves of dividends. So I, I think in certain places where you can get real efficient it's not good for healthcare.

[00:43:20] Griffin Jones: What about, what does this mean for the younger doctors in the field that they haven't built equity into their own practices yet. They're now buying in or want to possibly buy in. What have you seen from other fields, of the path that this creates for younger doctors?

[00:43:40] Dr. Laura Olson: A lot of physicians are worried about this. They think that private equity is changing the whole nature of opportunities, certainly younger doctors who have huge. Greater than ever can't afford to buy the practices of retiring doctors. So they end up working for places, whether it's private equity or healthcare systems.

So I think the whole nature of being a physician has changed. And I think that what do we have today over 50% of all physicians are now employees and that's increasing and they're going to be working under the, if they work under the conditions of the private equity, they will be basically told what they can and can't do to try to we as operations, they can say, for example, one of the fertility doctors told me that what he likes to do is have flexibility and he decided he would never go into private equity because he really needs this flexibility.

One of the flexibilities that he likes is that if a woman needs another, a second round of fertility treatment for her, , what is it, the in-vitro fertilization IVF, if she needs another round of that he'll give a re a really reduced amount and even more reduced, does she need to third amount?

And he said private equity would not allow that. So there's also a lot less, he argued, there was so much less flexibility to do what you think is right and you practice. 

[00:45:16] Griffin Jones: I do hear many physicians say that many physicians do do that. They're just nice people. They have a relationship with a patient and they want to help out in some way.

I've imagined private private equity backed partnership group might say well, but that's well, that's ad hoc. It's dependent on the doctor, his relationship with this individual. And they're doing that because they don't have a financing program in, in place. It's more equitable and scalable across the board.

I could see that being something where they say, well, that's an example of one of the inefficiencies of private practice that we're able to scale across by having more providers and more resources.

[00:45:59] Dr. Laura Olson: Is that a question? 

[00:46:00] Griffin Jones: I guess it wasn't a question. It's just what they say. I find myself on either side. I constantly Laura and I was recently on the other side of asking the younger physician question to an REI who I really respect that I've done business with, know the person who and believe this person to be a very genuine person who feels that it actually benefits the younger physician more.

And I can't really get my head around it. And because well, one is what you're, when you're cashing out, you're cashing out on future earnings. And so I would want to be more in control. Of my future earnings, I suppose. That's the argument. And for those of you taking that side of the argument, you can tell me if I'm not doing it justice, but you're saying if the, if the private equity firm backed from the network is able to create something that is worth more than then I'm, I'm getting the chance to buy in to something that's going to be work worth a lot more.

But the way I see it as if, when you're selling you're cashing out on you're exchanging that sale price for future earnings and I'd like to be able to affect that if I'm a younger doc and two is the multiple is often dependent on what you've been able , to build up, like the multiple is coming from your sweat equity.

And if you don't have a chance to build that up. So somebody can tell me where I'm wrong, but that that's where I go back and forth. Laura's I'm looking for I guess we don't have those case studies yet for, for younger versus older docs, but it seems to me that many of the older docs, that it seems to me that many people are doing this for an exit that they can't sell it to the new REI fellow, because that REI fellow has $400,000 of debt.

And because the price has gone up and all right, well, now I'm able to sell this for 6, 10, 12, whatever the, the there's trapped equity, at least it's trapped to the potential partner doc. They can't, they can't buy it at that price. And so private equity comes in and so how much. What did you come across with this being an exit strategy for older doctors?

[00:48:13] Dr. Laura Olson: Well, I think, one of the things we're talking about was the quality of care for patients and clients and the conditions for working conditions for physicians. When it comes to finances, doctors make money on this. What they do is they get a piece of the equity. They get lower salary, usually they lower the salary, but they get a piece of the equity when it's sold. They get a piece of the sell price. And when they buy, they stay with the firm and they sell it to a new private equity, they can get yet another piece of the sell price. So for young doctors, it could be financially. But the price they're paying is losing their freedom to be a doctor and do the two the procedures, the way they want use the equipment that they want get updated equipment to have trained personnel have long relationships with clients.

I mean, they pay a price for that, but I never said it wasn't lucrative. They could make good money. As far as the older physicians, they will tell me, this is the only exit strategy I have, because as you said, the young doctors can't afford to buy my practice. Now they could also sell in some niches to a hospital health systems.

I'm not sure my guess would be, and this is purely educated guests that they make more money in private equity, but they have more control, but the health systems. So I guess what physicians have to do is make decisions about whether they want long-term gain from selling at the price of losing their freedom, to be a physician the way they want.

[00:50:05] Griffin Jones: Well, how would hospitals be any different? The hospitals is having every bit, a little as free freedom as a oh, there's two questions that I have with hospitals is one is I see them as having every bit of little as freedom as not being in private practice, because you're not the boss you have, you've got a division chief and then a dean of a department.

And then there's folks above that that are tied and they have procurement and purchase orders. And so a lot of decisions are, are made ahead of time. So I see one hospitals having even less freedom or perhaps the same as, as a potential and two, we're starting to see hospitals sell off the IVF centers of their REI divisions to private equity-backed networks as well.

So wouldn't you just be back in square one? 

[00:50:56] Dr. Laura Olson: Yeah. And that case you would be something I, I grappled with I talked to people about Ithought, a lot of that. One I lament the demise of the independent physician. I think it's a really negative thing for this country that we have lost, we're losing that at a steady rate.

But at least in a hospital system, it is headed by a medical personnel in private equity. It's headed by finances and I find it more troubling to have healthcare, like the whole corporate control of medicine which is basically not allowed. But here you have Financiers, the people that I talked to in fertility, for example they were two friends, one that met in the Wharton school.

One went into private equity and the other decided the buyer fertility fertility com company, and they got together and put together a fertility company. There was no medical personnel involved in that. And I find that with hospitals systems, at least, and I could be wrong on this. And the doctors that I've talked to that belong to a hospital systems don't seem as unhappy as the ones that are controlled by private equity, but at least they have medical experience.

They care about the health care, even with all the bureaucracy, all the problems and.

I can say, it's great thing that the hospital system, excuse me, a buying of docs. But at least they're in medicine that care about health care. 

[00:52:32] Griffin Jones: I also worry about just consolidation in general, limiting competition, limiting. I think that's w that's one thing that's really good about a free society and free markets in a society is that you have on one end democracy bends towards chaos.

We give everybody a voice and everybody ends up voting in their self interest and everything is diluted. And on the other end authority bends toward tyranny and the point of having a system where different people can compete. Is that okay? They're all tiny little authorities and the ones with the better ideas and better systems are able to grow and advance. But if they do that to the point where they're just consolidating and introducing financial systems that aren't necessarily aligned with the rewards for productivity in that system, then they bend too far the other way.

So I'm going to let you conclude how you want Laura, if you want to conclude the way, the same way you concluded the, the book or if there's something else that you feel you didn't get a chance to, to cover in this conversation that you feel is really important. How do you want to conclude about this topic of private equity consolidating and purchasing more of the provider groups in healthcare?

[00:53:52] Dr. Laura Olson: Well, I go a little further. I work with a lot of groups that are interested in this issue. They're very excited about the new Chair of the SEC, where the he's trying to put more accountability to the private equity firms. Warren's Stop Wall Street Looting Act, I think is an important piece of legislation that also tries to give workers account accountability  for workers that tries to get more transparency.

Clearly the secrecy has to stop. Because not even the limited partners with their public, pension funds know what's going on. But I go even further. And this is not in my book. This is something that I came to a year and a half later after spending more and more time on looking at the health care niches and what's going on.

I think that the private equity should be prohibited from health care. I don't think it's a place given their playbook and what they need to do these are billionaires. These are people who have really sucked down from our healthcare system. One of the big problems that we have in healthcare overall is it's 21% of our GDP.

I teach healthcare in class and the last time I looked at was 19% about a year or two ago when I decided to update and I was shocked, it's now 21%. So private equity is increasing the cost of healthcare by the monopolies that you were talking about. I would eliminate all the advantages that they have, the financial advantages such as a carried interest loophole,their ability to take off the taxes the interest on the step and things like that.

I would strongly limit any debt that they can have at least on healthcare. I don't think they should be allowed to have 67%, 80% of dead owner fertility clinic. Oh, and I would also, one of the things they're hungering after is 401k money, billions and billions of dollars in of savings which looks like they may have access to more and more.

I would have prohibit that. And I also gets one of the things you were talking about. I would prohibit stealth branding that when I go into a dentist, I should know it's a private equity owned dental practice. So those are the kinds of things that I think are really necessary, at least in the healthcare area.

Because you, you seem, like you're not sure, and I'll tell you, there's so many people that I deal with that are not sure. But the more and more I study what has gone on and what continues to go on I've concluded that private equity is just detrimental to health. 

[00:56:38] Griffin Jones: Her name is Dr. Laura Katz Olson.

She's the author of Ethically Challenged Private Equity Storms US Healthcare. We will link to the book in the show notes, Dr. Olson, Laura, thanks for coming on the show. 

[00:56:49] Dr. Laura Olson: Must it been a pleasure and thanks for having me.

136: 6 Pillars for your IVF Center’s Killer First Impression

This week on Inside Reproductive Health, Griffin shares the 6 pillars to generating the best first impression for new patients, and how that can directly impact both your bottom line, and the patient experience. Listen to hear how you can build a successful New Fertility Patient Concierge Team. 

Listen to hear:

•  How (and why) to put the right people in charge of your patient’s first impression 

• Griffin explain how to emotionally incentivize your Concierge team.

• How to measure the Team’s impact on your practice’s bottom line.

Read the full article here: https://www.fertilitybridge.com/inside-reproductive-health/6-pillars-of-a-new-fertility-patient-concierge-team-ntwkw?rq=impressions

135: The only way to keep fertility staff from quitting when you can’t replace them fast enough? with Steve Rooks

This week, Steve Rooks, COO of The Fertility Partners, and Griffin discuss how entities like EngagedMD and the Lean system work to reduce employee burnout and improve the patient experience. But can programs like Lean fit into the fertility space? Is the EngagedMD approach of automation helpful to the patient, or does it cut down on valuable patient face-to-face interaction? Listen to learn more.

Listen to hear:

• Griffin question the one-size-fits-all approach to Lean’s operations solution, and whether or not it works in the fertility space.

• Steve Rooks explain how it is possible to add patient value and reduce operational volume at the same time through automation with programs like EngagedMD.

• Griffin question the viability of pre-packaged patient education in a virtual format vs. face-to-face physician conversation.

• Griffin and Steve discuss the importance of patient engagement during their (long) initial waiting period.

Steve Rooks:

Company name: The Fertility Partners

LinkedIn Handle: https://www.linkedin.com/in/stephenrooks/

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

Inside Reproductive Health is sponsored by EngagedMD. For technology that educates your patients with true informed consent, visit engagedmd.com/IRH for 25% off your implementation fee.

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Transcript

[00:00:55] Griffin Jones: Legal liability nightmares, losing nurses because of burnout really disappointing patients because of how long they have to be seen. These are some things we try to talk about avoiding in today's episode with Steve Rooks. He's the chief operating officer of The Fertility Partners in Canada and now in the United States as well.

And it's an EngagedMD sponsor episode. I brought Steve on to talk from that lens because there's a lot of business people coming into the fertility field. You don't trust a lot of them. You don't like a lot of them and maybe you like some people that I don't and vice versa, but I want to present Steve to you because he has the heart of a teacher.

And whenever I'm assessing, can I trust someone? What are they like? I look to see if they have the heart of a teacher. I hope I do, but I think Steve does definitely does because he also has the heart of a student. He started at IBM, his career decades ago. He has a mechanical engineering degree. And then he later he got his MBA.

He's worked for places like Verizon in Bell Canada and private equity portfolio that has served a lot of funds in their portfolio. And he comes to the fertility with the lean method of management to add value, to increase efficiency, to reduce the burnout and the burden on staff. And we talk about how he used EnagedMD as a part of that.

And we've had so many people on the podcast talk about EnagedMD long before they were ever a sponsor. And I wanted to unpack more of why, like, why is this so resoundingly positive. Why is it sort of disproportionately positive? And so I thought Steve was a good person for that, as well as educating you on a lot of different ways of looking at your practice to improve systems and avoid losing any more staff than you have to and avoid taking off any more patients than you have to.

I hope you enjoy this episode with Steve Rooks, from the fertility partners.

Mr. Rooks, Steve, welcome to Inside Reproductive Health.

[00:03:03] Steve Rooks: Thanks very much Griffin really excited to be here. As I mentioned before, I've learned so much from your podcasts, that my being on here is a real pleasure. 

[00:03:12] Griffin Jones: I was saying to Stephanie from EnagedMD at I think it was PCRS. I got to have Steve on the podcast because he's been such a sponge in the fertility field.

I don't know if it's been about a year or so for you have just been these sponge. I see you in all places, just really learning a lot of people come into the field and they're like, oh yeah, I want to learn. And, but often they're just coming with their own agenda and just kind of tailoring it to that and you really seem to be learning everything.

So tell us a bit about your background. What are you coming into the field with?

[00:03:46] Steve Rooks: Sure. It's been a background that as I've been more about learning a lot, being challenged, but more importantly, supporting the success of others starting, as an engineer, by education and then going on to do my MBA and then working as a management consultant where I worked across multiple industries, helping executives improve their business in a wide range of situations, both top line and bottom line.

And then taking that experience into the corporate world doing some work that had a very customer focused transforming the customer journey and the equivalent of Verizon in Canada called Bell Canada. And then from there going into private equity. So I spent real last 15 years working on the portfolio side of private equity for the likes of TPG capital, sun capital, Ontario teachers' pension plan and a number of others.

And from that, it was about working with the, the portfolio executive management and helping them again, really improve the, their business with a focus on value creation on improving customer value prop, but for me as a person going in there, I had to learn very quickly , a wide range of industries and get up to speed, to establish credibility, to help them.

So that's kind of in the basis. And that's why Dr. Andrew Michael our CEO and founder of Fertility Partners. I had a recommendation of the private equity company that invested in this. Called me up and said, Hey, would you like to try something different? So I was at that time at a private equity company and he laid out the opportunity to come to the fertility partners and really scale a platform to support the clinics, be that much better.

And to me, looking for my last gig, as I would say, my last real role before I look to semi-retirement, this was a fantastic opportunity. And got me excited was as part of that process, I spent some time talking with three of the REI's at our leading clinic, all the fertility in Vancouver and their passion and their excitement and their desire actually to improve further, even though they're already that the best one of the best clinics in Canada really motivated me to want to come on board and support them in becoming even better.

[00:06:05] Griffin Jones: And that's why they want a systems thinker. And you're clearly a systems thinker from your engineering first, then managerial consulting. And then getting your MBA. You're very much, a lot of people have the chief operating officer title because it's the title that was maybe available to some kind of senior executive.

It seems to me that actually a chief operating officer, you really an operator. And so at what point did you come across the Lean Method and will you give lean management an intro for the audience that might not be familiar with it?

[00:06:37] Steve Rooks: Sure. My very first exposure in, in a, in a really serious way, was it drew my first exposure to private equity at TPG capital. TPG is a big believer in lean, and we initially were using it in was in an orthopedic manufacturing environment.

And in the course of seeing how hips and joints knees were made, I also saw how it was applied in orthopedic surgery environment with one of the orthopedic surgeons would use Lean in his offering Belgium and I was really amazed. And then I was asked by TPG surprised me to implement lean at the Caesars and Harrah's casino operations, post global financial crisis, where all of a sudden they had to , look at ways to reduce costs.

But the beauty of Lean is it's not as hard. It's not really a cost reduction exercise. It's about starting with a view of what's value-add to the customer or in our case, it's here in fertility, the patients. And those steps in a process that aren't adding value for the patient in terms of their willingness to pay that is creating value for them are just steps that are adding time and costs to their journey.

And therefore the lean toolkit is about taking out those non-value-added steps and finding ways of working with the team so that I had to implement lean working with a team across 22 properties over nine months. And we applied Lean in every single process in the casinos and the beauty of that as I could see the impact across a wide range of processes, more important.

The other aspect of Lean that I really like is the bottoms-up process. That is you actually engage the people who work and work with the patients, work with the customers. They're the ones actually stepping back and, and with support from facilitator, looking at the process, looking at the wastes, non-value-added steps and finding ways to take it out. And then by the end of the week, cause it's typically a week long exercise, they then have a very clear action plan of what needs to be improved. They've established at least five KPIs that will measure their success and their progress. And then they have an approach going forward that will drive continuous improvement.

Most important, I can't tell you the number of times at the end of one of those weeks, hearing people so motivated where they said, look, this is the first time I felt like I was a part of the process to improve my area. I had real ownership and a stake in it, and that was really gratifying. So that was my, since that moment, literally 15 years ago, I've been a big believer in Lean and seen it have impact across a wide range of industries, service, manufacturing, distribution, et cetera.

[00:09:20] Griffin Jones: So how does that translate into a field where there's emotions, where there's a standard of patient care? I could see it, working on a Toyota manufacturing line, but when you have so many variables of one, there's just so many different kinds of cases to treat and different kinds of patient populations.

And then you have the human element, emotions, relations, human. And how does this Lean method translate to fertility? 

[00:09:49] Steve Rooks: Great, great question. And again, it starts with the view of let's really focus on what's value at patients and how can we enhance that value add? So whether you apply it to the intake process to cycle monitoring, even in the lab, for example it is stepping back and saying, okay, we mapped out this journey from a patient perspective.

Let's map out all the times that they wait, let's map out all the times that they are dealing with issues from a payment standpoint, from a testing standpoint, et cetera. And let's find ways to speed up that journey and remove any constraints or irritants that they experience in a way that again, adds value while still ensuring quality and more effective outcomes, et cetera.

So we hadn't in the clinics that we've applied this, now we've done it in at least two, but we have another three lining up to do it. And we did it in the best clinic and we did it in one plant that needs a little more improvement. And in both cases, it starts with mapping out the entire value stream in this case the IVF journey for a patient. And he actually starts at learning that they're pregnant and moving back through the journey to the intake point from the referral point. And in that process, we identify all the areas that are constraints or issues or bottlenecks. Or pain points for the patient and for the participants that add value in the process, and you bring together a team of REI, of nurses, of an admin of lab, a tax, et cetera.

So that they're all aware wanted the great strengths is just understanding that where the constraints are from end-to-end. And so we'd have REI saying, wow, I didn't realize that my asking for this caused this issue downstream. And through that process, then we identify all the years to improve. And as an example, an intake from referral to first consult, we, the lean exercise on that really focused on how we could improve our capture information and to get to the patient, to the consult earlier, more fully educated with all the testing done, et cetera.

So they can have a much more effective first console. So through that process, I think everybody involved from the REI, two nurses through the intake coordinators, et cetera, they all realize the value of doing this. And they all end up at a, at an endpoint design of a new process that they all feel really good about, that they feel is gonna be more value add for the patient.

And we've established the KPIs and how do we measure success going forward? So that's that, that kind of outcome really drives a desire to apply it to the next area that could be improved, like cycle monitoring or the lab, et cetera. 

[00:12:30] Griffin Jones: Then how did EnagedMD pass this value test for you? Because it seems like this type of system would be, and I'll say that EnagedMD is, this is a sponsored episode for EnagedMD, but you were at the association of reproductive man, where you at, you were at the RM meeting. 

[00:12:46] Steve Rooks: Yes.

[00:12:46] Griffin Jones: Right. And it, like people just started getting up and it was like, oh, you are going to be sponsoring me or is he sponsoring all of these guys? Because it was, it turned into like an EnagedMD commercial from everybody just standing up and talking about the value, but I see a system like this is often like about eliminating things and you go through we don't need that software.

We don't need that bell or whistle. And and with this process, it seems like you added in EnagedMD. So how did they pass this value test?

[00:13:16] Steve Rooks: Well, I hate to sound like a commercial, but the first time I heard about EnagedMD was on one of your podcasts. And I immediately thought, wow, that makes a lot of sense.

And as part of the process, we're in particular, we looked at intake and saw that for some clinics the education process. So the value-add for the patient of really understand their journey, understanding their options, and being able to have a very good discussion with the REI in the first consult about their options.

That to me was an area that was it a challenge to do well for most clinics that weren't, didn't have a, a more effective approach. And in addition, the informed consent component as, as my good friend, Dr. Steven Katz would tell us many times is not typically done well. And so when I saw EnagedMD, I saw it as a big end.

Both really did a phenomenal job in educating the patient, tee them up for the consult, ensuring effective, true informed consent. And it added productivity because it reduced the amount of time that the conditions had to spend with the patient because the patient can now do it themselves at their own pace.

And we can ensure they understand it going into the first consult with the REI or after if that's the process flow. So to me, EnagedMD was a clear value add for the patient, but it also helped improve productivity and effectiveness of that task of educating the patient patient, ensure that you have proper informed consent from them.

[00:14:48] Griffin Jones: Well, , let's talk about that clinician piece for a second. That piece of them having to spend less time with the patient on a particular topic. Some people are concerned about that. They're like, well, I want to spend my time with my patient or our patients are coming to me for a reason.

And I want to give them that time with me as opposed to a module. How has that played out for you all? 

[00:15:12] Steve Rooks: Well, the beauty of this approach is that those steps that are very common for all patients. So in this case, educating about the basics of the fertility journey or even the details around PGT or other value added services within the journey those are common steps for all patients.

 So how do you EnagedMD where you can offload that common engagement with but then spend your time on the specialized, personalized engagement with the patient. So you can focus on their particular issues that frees up your time. And that's the same thing with the REI consult or the nurse coordinator engaging with the patient.

The common stuff is handled offline with the patient via the EnagedMD module, but then the personalized discussion about what does this mean for you? What do we have to do for your specific that gives the REI and the clinicians more time to really focus on the personalized aspect of each patient's journey and less on the common aspects?

[00:16:17] Griffin Jones: Yeah. Because otherwise the clinician is doing the job of the module, right? Like the clinician is simply a replicable recording. If they're doing the, A, B, C, D E checklist. But if the module is doing that, then the clinician said, oh, you didn't really understand. See, let me talk to you a little bit more. Oh, there's a bit more of D in your case.

Why don't we spend some time talking about that?

[00:16:41] Steve Rooks: That's the beauty of EngagedMD with their knowledge checkpoints through the education modules, the commissions have an opportunity to understand where a patient was having issues and therefore just focus on those areas. Whether that's, again, it's in PGT or in stimulation, et cetera.

It allows them to focus on where the patient themselves have had some challenges and understanding the journey. So it really allows that focus in that value, and where it's needed. 

[00:17:08] Griffin Jones: I can't stress it. I do it in our own sales process and how much it helps. I don't do it as efficiently, is in EnagedMD where they've got like a whole module.

But I do have, we have a system for when people come in through the goal diagnostic, I have some articles and some pages on my site that I send them. So that by the time I talk to them and they're, they're filling out some information for me. So by the time I talked to them, it is not just that, what do you do? Who else have you guys work with? What, like, what are the types of strategies you work on? We're focusing on, this is what you all need to do. And so it's like, they're still getting my time, but it's far more tailored to them. It's far more valuable than me serving something that a webpage could do. And it seems to me like EnagedMD does that for patients really well, especially. 

[00:17:58] Steve Rooks: And actually we started the process of really innovating in our intake process that, and this came out of Lean as well as some additional work that I was doing with Dr. Dan and Gary Tokuda at all, it was really trying to make the intake process more efficient, where we're doing initial triage with GPs as an example, we're nearing on a digital platform to help really improve the process for the patient. But the key thing is in that initial triage, before they hit the first consult, we have the ability to understand at least to some degree what their journey may entail though. The REI will confirm it in the first consult, but what we can do that is where we have some unique challenges for a given patient.

We can tee up the EnagedMD module. That's most pertinent to them. Many clinics are using EnagedMD might wait until after the first console to do the education. We feel it's important to tee up those unique aspects ahead of time so that when they have the conversation with the REI they're ready had some pre-education. So it's a much, again, it's a much more fluid. Value-added conversation rather than the REI having to do the education aspect first. So that's an important distinction that, many clinics haven't necessarily optimized, EnagedMD. Cause they look at the costs and say, well, we should do it after when we know that they're definitely a patient as part of the conversion process, we feel though it's me and more value-add head of the first console.

If you have a sense that, okay, this patient may need PGT as an example, and we can provide that ahead of time. 

[00:19:31] Griffin Jones: I wonder if some guys are thinking, well, I have a contrarian point of view on many things. I think if you have a contrarian point of view, it's even more important to have a baseline because otherwise, if the patient's just deer in headlights, they don't even know what you're being concerned about it.

And they don't even know like other than, like, oh, that sounds good. And then they Google something else anyway. But if there's a baseline and you can say, what, on this specific point. I take this approach and I feel like if you're a contrarian, it's all the more important.

And I've just heard, at that our meeting, you started sounding off on EnagedMD and everybody else just kind of started doing the same thing that I know I'm biased because they're a sponsor for us. So everybody knows my bias. They're a sponsor for us though, because I've known them for seven years and I've talked to them about being a sponsor way before I talked to anybody else, because I just keep hearing positive things. And I'm not saying that there's nobody with negative things to say about EnagedMD I'm just saying I haven't heard it yet. So if you actually have negative things to say about EnagedMD email me. Email me.

No, not you. I mean, the listener like email me because if you exist, let me know you exist. Otherwise I don't have any evidence that they exist. I just keep hearing these really good things, but. 

[00:20:51] Steve Rooks: If I can add something there, one great thing that they've done for us as a true partner, because they definitely have a mission for properly educating patients as a true partner, we needed, of course in Canada to also have Quebec, French versions of the module done. And that could have been a very expensive proposition, but they partnered with us and they were very transparent and basically just past. The pure cost of having it done properly by a third party, with a French, with a French Canadian group that helped us get these, these modules up and running for our Quebec patients.

And that made a huge difference. Furthermore for some of the more unique languages that we have in Canada, like Punjabi or say Mandarin, et cetera they have been very quick to say, Hey, the fastest track is to put subtype. For those languages and all our videos, and they've been very supportive to do that quickly in a very inexpensive way.

So I'd say now in Canada, in our clinics, we have the ability to support all of our patient base, irrespective of their language with this, these education modules, which makes a huge difference for them.

[00:21:59] Griffin Jones: We've been talking about the value-add for the patient, but I think the real. Golden, the, the silver lining or the golden bonus, whatever you want to call it is what it does for the staff right now.

Because if you're listening, like how many of your nurses are just sitting on their hands? Like not one of you and not one person listening has a nurse that's just got excess capacity and And nurses are leaving and they're burnt out and they're going per diem other places. And they're going to other parts of women's health or other parts of health care.

Some of them are leaving healthcare altogether and you can't replace them fast enough. You're already trying, I'm talking to you, being the, everyone, all of us are trying to recruit as fast as we possibly can that to exceed retention, we're all in this boat across the marketplace in the workforce, especially with nursing and healthcare.

And you can't replace them fast enough anyway, and you need to get stuff off of their plate that they shouldn't be doing. Can you talk about like that at all? Like with the reduction of burden to the staff? 

[00:23:09] Steve Rooks: Exactly. I mean, that's part of our mission on our innovation that we're trying to bring to the platform.

So looking at as we look at the workflows through the Lean exercises and looking at opportunity again, if it's, non-value add a it's not patient facing, then we're looking at ways where we could automate steps and really improve the flow. So it's not just nurses, even the admin. A lot of our admin still are faced with the issue, for example, of transcribing fax referrals the EMR and that's a huge pain because of lack of integration. So, we're looking at an EMR that that would allow us, for example, to take he faxes and leverage some of the online services that can transcribe. With a strong focus on, on medical faxes transcribed and put them into the EMR.

So that's a step that typically takes 20 to 30 minutes of MOS time, medical office assistants time and typically results in errors. So our goal is to automate a lot of those things, reduce the errors and ensure that all of that is fully captured. On the backend many of our EMRs aren't properly integrated with our billing and, and accounts payable system.

So again, that's a lot of manual work that we are targeting to handle with our EMR. So throughout the value stream we're finding ways to augment all of the players in, in the, the value stream in terms of their roles. So they can focus on patient facing value added steps, for example. And I want to refer, for example, to another thing I heard that Dr. Sable once mentioned, and I think Eduardo as well around, the future of AI. So looking at our new EMR system as a way, for example, of across our clinic network being able to augment the REI by saying, Hey, for this type of patient, with these hormone levels, here are the top five protocols that have resulted in the best results. Now that's still up to the REI to make a decision about what needs to be done. But it's a way of augmenting their capability and bringing value to help speed up the decision-making around a given patient for example. 

[00:25:15] Griffin Jones: So you mentioned informed consent as one of these areas that patients are getting true informed consent.

Yeah. I'm not leaving counsel, neither Steve. So we have to give that obligatory, disclaimer, that always talk with legal counsel, but when you're looking at informed consent, it's like, okay, did this person really have informed consent? If it's a stack of papers, maybe they don't speak the language that, well, maybe it was rushed.

Versus they had an online module where they watched every single one, they took a quiz, they had it in their language. What holds up as, as better as informed consent and Dr. Katz says, it's obviously the video obvious and so but that kind of talks to the effectiveness, but is there any efficiencies?

And if there isn't then talk about that, but is there any efficiency saved with EnagedMD the, in the video module or excuse me, in the informed consent part of well now you're not tracking down people for, if did they. 

[00:26:15] Steve Rooks: Oh yeah, I can tell you that before EnagedMD to do it properly at least to the level that, Dr. Katz would bless us. Okay. That's sufficient informed consent. We would have nurses spend 45 minutes to an hour sitting down and working through the informed consent forms, ensuring that the patient was fully understood each clause, et cetera. And then to get them to sign. And so, again, when I stepped back, you would say the informed consent is important, but it's not necessarily value add per se for the patient in terms of getting pregnant.

It's an important legal requirement to ensure that they understand what they're going through, but that's a step where if you can have something in place, like EnagedMD, be that ensures that the patient went through has the knowledge check points and then ties it into the specific portion of the informed consent form in their language, because that's the other great thing about a EnagedMD, not only the modules, but the actual forms themselves can be there, their language.

Then you truly know you have informed consent and you have an audit trail that you can demonstrate if a bad case scenario happens and the patient comes back and tries to claim, lack of informed consent, you have that audit trail to be able to prove otherwise, now you hope that never happens, but that stuff does happen every now and then.

And you want to be able to have that audit trail. But not spend the time that was required before yet something to EnagedMD to do. 

[00:27:47] Griffin Jones: So that's so much time for the nurses saved. I just like anything that we can get off. The nurses, the mid-levels the providers plates. I want to get off their plate.

If you just look at, when you think of like the cost, say like when you compare the cost of like how much time you're saving for your providers, how much you'd be saving on recruitment by not having to hire recruiters or how much are you saving on retention to me? Like the cost benefit seems there now I think more than half of clinics in north America are using EnagedMD. So we're beyond the tipping point for those that, that aren't yet. I suspect that it's just because like, it's just one more thing that we want to think about. And so for, for them, They might be at a point where it's like, okay, is the juice worth the squeeze?

Is it like how much implementation is going to be there? So can you talk about how many clinics did you unroll EnagedMD for and how did you go about enrolling at?

[00:28:48] Steve Rooks: Oh, as soon as I learned about EnagedMD, I literally teed this up within a month, now of course, as with the fertility part, we can't tell a clinic what to implement.

We have to sell it to them. So I became Jeff and Stephanie's best sales rep working with all our clinics. I liked the value now fortunately, we already had our largest clinic, all of using it for a while and they were able to point to the value in terms of true informed consent. All the savings from a nursing time standpoint, admin time standpoint, but also just having a better patient experience with the modules.

So I was able to sell all our clinics very quickly with the only final hurdle being the French language requirement for the Quebec clinics. But we worked through that. And so we literally had EnagedMD rolled out in multiple waves over, I'd say a four month period at the most eight clinics right away.

And then the other three Quebec clinics we're. Now we finally have the translations and they're implementing now. And they're very excited about that. So it's basically all of our clinics and the impact has been huge, as I say, from a education, patient experience and ensuring true informed consent.

Cause we all know. We've all faced those forms online, where it says scroll through everything and inside the bottom, everybody just scrolls all the way through and then sign. So the time that the nurse would spend having to ensure that they went through properly, it was very painful and time consuming.

And now we know that the patients are doing it properly. 

[00:30:19] Griffin Jones: It's not the Apple consent. You can't just do that. Hit the long thing that who knows how many firstborns we've all agreed to give away because none of us read those disclaimers, so, okay. So you have to sell it to the clinics you got them to buy on in about four months, you were able to unroll it. How does it start? Like, let's pretend we're one of those clinics, like, and maybe, they're not working with the Fertility Partners. So they call Jeff and Stephanie sales team and EnagedMD. Then what happens from there?

How does it get into the practice?

[00:30:52] Steve Rooks: Well, basically first, I mean the very first thing is for the, the actual clinic to review the modules as they stand today, to understand what's in them and make recommendations. Well, not just make recommendations to require some modifications. So for example, here in Canada, there's a slight different way we practice, some of our approaches in protocols, et cetera.

So all of our clinics had the opportunity to say, okay, I want this language changed a little bit. We need to change that there and EnagedMD is very accommodating, they will make the necessary changes on a reasonable basis without any extra charge that's part of the process. The French language one was a whole new step, which did require some additional costs.

And we all agreed to that very transparently. So the first is to modify the modules as they see fit. And it indicated how. And then the team in parallel works on the informed consent form. So digitizes their existing informed consent forms provides necessary translations. If you needed to say English and Spanish or French, et cetera, and tee those up and work with the team to then decide on the workflow.

So helping the nurses understand how to push it out, how to designate the particular modules for a given patient, et cetera, and how to access it. So the total at a given clinic, the, the implementation time really is no more than two to four weeks max, in terms of making the changes on the modules as needed.

Digitizing the informed consent or taking the clinics are informed consent forms, digitizing it, and setting up on the platform and then doing all the training. So those nurses who are engaging with the, the patients that need to assign the modules to the patients, they go through the training process too.

So it can take less than, than four weeks for you to get at a given clinic it up and running and having an impact with your visions. 

[00:32:48] Griffin Jones: What are some of the hiccups that can happen like in, that's, that's pretty quick, like are there any hiccups that people should know about? 

[00:32:57] Steve Rooks: We didn't experience any real, I mean, the only area would be just ensuring that the content was in sync with the way that the clinic practice fertility treatment though, again, then that was, I think a little bit of a Canadian US type of change, but I imagine within the US in particular, there'd be very little hiccups there per se.

Because they were constantly ensuring that their modules are reflect the latest and greatest day of the. When it comes to treatment and approaches, et cetera. And we did, though, they're very good ,on LGBTQ in terms of representing that we did make some suggestions about adding on some additional representations. So we could have support our LGBTQ patient base a little bit better with the educational modules. 

[00:33:44] Griffin Jones: And that's all part of the beginning, part of the process where you're making, you're modifying it to your center's standard of treatment, and that's all part of the standard process.

[00:33:59] Steve Rooks: Exactly. 

And the other thing too, and the thing I like about EnagedMD they do allow you also, if you bought some very good, very specific modules, like an introduction to the clinic and other things they can also host those modules to be able to push out to the patient. I forgot to mention too, they completely white label everything so that the videos all have the branding, the logos, et cetera. As well as of course the informed consent, sir, are identical to what you would have on paper at the clinic. So that's the other key thing is that ability to add in additional video modules that may be produced.

We have one clinic. I'd say more than half of its videos are its own. While the key ones for informed consent standpoint are EnagedMDs. So that's another flexibility that's quite good. 

[00:34:48] Griffin Jones: Was there anything, cause I had to go, I'd go catch a flight at from the RM meeting this. But was there anything that people said that other people didn't really know that they, oh, I didn't know, you could use it that way or we're using it. Like, was everyone using it the same way? Or was there any diamonds in the rough that people fake, oh, I didn't know. I could do that. 

[00:35:09] Steve Rooks: Well, I think it's things like position is when you position the modules so that you can tee up a patient to be prepared for a discussion.

Ahead of time rather than post consult so that it's a much more informed one. The other thing that's great about EnagedMD is that you're alert. You can easily for use with, for training. So as we bring on in particular medical office assistance, admin, et cetera we can leverage the EnagedMD modules to quickly get them up to speed on fertility treatment.

And that's another great thing, especially with the knowledge checkpoints, et cetera. We're not going to get them to do the informed consent, but the training aspect of those modules are fantastic. That have been really helpful as we brought people on into the clinics. 

[00:35:54] Griffin Jones: Well, let's talk a little bit about that pre-consult use because also we have to do something to keep patients engaged for these gigantic wait lists that most people have right now. So the Fertility Bridge position is that the sweet spot of waitlist is between two to five weeks. And everybody's not everybody, most people are past that right now.

And under two weeks, it's just like, what are you doing? You're in big trouble. But over, over four weeks and people, oh I'm an expert, I want to be, I want to have an eight week wait list. It's like, okay, fine. But in a millennial world that four weeks is a ton. And so to have like six week, eight week, 10 week wait-lists, which many of the people listening do?

Like, we need something for the patient in that time. We create materials and things but they also. Yeah, they also need stuff for their treatment. And if, if they can get this education that is white labeled through the practice, then it's like, oh, I'm still participating with the prac. I'm still moving towards my treatment.

I'm still moving towards the answer. I'd get in a consult, even if I'm not going to be seen for another three weeks. 

[00:37:03] Steve Rooks: Exactly, Yeah. And that's the great thing that EnagedMD is now wanted recently, but developed when we implemented was they have two tiers of modules in terms of details.

So there's kind of like the foundational modules, which are very low cost for patients. So to me, those ones are a must ahead of the concept. So it's like fertility, one of for example, and that tees up the preliminary aspects of fertility ahead of the console. Now we've gone one step further. So in addition to those foundational modules, which are very inexpensive to put in front of all patients whether or not, you're going to convert them to IVF or not.

We also, as part of our triage are trying to determine some of the likely added treatments that are necessary, whether it's exi or potentially PGT or other aspects. We can then look to tee those up as well, too, if we're confident, as opposed to doing it after the consult to do it ahead of the concept to help ensure that the patient's well-educated ahead of that, the other things may be modules around some of the value-added services about how nutrition and mindfulness and , wellness, et cetera, can really help on the journey.

And we're using that as a way to teach. As you've certainly highlighted and some of your conversion podcasts that notion of attaching the value-add services ahead of the console to engage them in the process ahead of time. So that could be teed up by some of the modules, and then we can offer that as you're waiting for that first consult as a way to initiate the engagement around wellness, mindfulness, nutrition.

[00:38:41] Griffin Jones: Yeah, that way they're not only are they informed, but they also feel like they're being served. Like I'm not just waiting in line for me to pop into this office. And in eight weeks that I'm working towards something on a journey, it's a really good, it's a really good thing to be able to offer right now.

So we talked about the, the necessary burden relief for the staff. We talk about the value, add to the. I want to do a little free consulting for Jeff and Taylor on air right now. I don't know what have you got any NDAs in place or whatever? And I don't know what their product roadmap looks like either, but just in terms of either what you'd like to see from them or what you want to see, somebody in the, in the field produce to offer a lean solution, what would you like to see come out as a technological solution in the next year to three years?

[00:39:33] Steve Rooks: Around EnagedMD as a platform? 

[00:39:35] Griffin Jones: If you can think of something and if not, then in general. 

[00:39:38] Steve Rooks: Yes. Yes. As I say are our key things is around the language, so that was one they really addressed well, and just enhancing, of the modules in terms of knowledge, checkpoints, more and more knowledge checkpoints that again, going back to what Dr. Katz said by having those knowledge checkpoints and the ability to add more. So I, for example, would love the ability to easily tailor and customize the knowledge checkpoints given are some of the things that we're highlighting in the informed consent, so that I can be very certain that the patient understands some of these key points.

So to me, enhancing that true informed consent through those knowledge checks. It's really critical. So I'd want to really, to add more customization and flexibility around those. I haven't really pushed them on that, but that's definitely an area. I would add and oh yes, I do recall now I remember having a good session and is the ability as the patient is going through the modules to create a scratch.

So that those issues that the patients not really sure about, they can enter in that questions and the things they're unsure that can be captured and shared with the their nurse coordinator, their IVF coordinators and the REI. So those areas, so that goes beyond just having a set note checkpoint.

It's actually allowing the patient to interact. With the material and say, Hey, here's where I'm not sure about here's where I want more information. And that could be, that's actually a great way to further enhance engagement ahead of the first consult by enabling them to have Lira in those questions through the watching the EnagedMD modules, that's something I did highlight to them. And the other key thing is in tying that into the EMR. What's one thing we're working on them is to improve the, the integration of EnagedMD with the EMR to capture some of these notes and, and questions and pull them into the patient history as well, too.

So that would be a, another area as well, but I can see that value add is really enabling better engagement and insight for for the patients and being able to respond. That the IVF coordinator could see those messages ahead of the first consult and even provide responses back in a two-way engagement ahead of time.

[00:41:57] Griffin Jones: Oh, let's talk about th this concept of EMR is being able to talk to other software because I think this is absolutely was that I think that the concept that people are talking about. And the broader lexicon is a digital wallet and a data wallet, really not a digital wallet, like apple wallet that has money in it, but, or even not even at like a cryptocurrency wallet, but a data that those things would likely integrate, but like a data wallet.

And I'm willing to give some of my access to some parts of my data wallet in order to have a better customized experience. And what I want to see in the field is a CMR that integrates with all EMR psych and because everyone wants attribution. I've got a point of view on attribution that it will never be perfect, even if we have what I'm describing here.

But what I'm describing here will, we'll be closer, which is CRM, customer, relationship management, think HubSpot, Salesforce, SharpSpring, things like those, and integrating with EMR and what, what I'd like to see is that because otherwise it's like, it's just one more damn thing for the clinic that they don't want to have to deal with. So are there other things that you think like need to be able to talk to each other? And I think for those softwares that don't talk to each other, at least have the ability to in 10 years, I think they're going to be obsolete. I maybe that's wishful thinking but I think it's part of the reason I just had Gina on from kind body and they're talking about, they've got everything, like it's end to end they've got their own EMR, they've got their own scheduling software and it's like, well, that's might be part of the reason why, because in the meantime, if people aren't going to talk to each other, it's like, all right, well then we'll just create everything and it will talk to each other.

And so what do you think really needs to be able to talk to each other? 

[00:43:48] Steve Rooks: Well, I do your point. some of the sort of external interactions with patients have say within support groups, the ability of through CMR integrated EMR, the ability to understand and be able to to monitor the kinds of questions.

That are being discussed on, on social media group chats around fertility, for example, to, to provide greater insight around some of the issues that the REI is. And the clinicians may not be aware are. Issues for the patients, unless the patients specifically talk about it. So having that kind of awareness, that external awareness of what are some of the, the questions that are being asked, what I want to do in a way that doesn't feel too big Brother-y.

But I see it more as if it's done in an anonymous way to at least allow the clinics to understand that. What are some of the issues that are not being addressed properly in today's patient journey that can be addressed through things like EnagedMD through the, the education of the patient, the engagement with the REI is engagement with the clinicians.

So it's a kind of, I'm trying to think of the right word, but it's, it's having that knowledge of what's not being addressed today. And the typical journey that the patient experiences within the clinic walls, that they need to look externally to patient support groups, et cetera. And it can be done.

There's no reason that you couldn't be able to not honestly review what's going on in those jackets, but that would provide you greater insight on things that aren't being properly. 

[00:45:27] Griffin Jones: I want to go back to, to the point about staff and recruitment and retention. Is this at, is this happening as much in Canada as it is the United States with nurses being burnt out and going to others and going per diem and going other segments is the great resignation or what the great reshuffle it's now being called.

Is that happening in Canada as much as it is in the US? 

[00:45:52] Steve Rooks: I would say, yes, it's likewise happening here as well as, embryologists are also another group of class of, of of staff that are very difficult to find. But yes, there is that, that burnout with the nursing staff, et cetera. And that's one of our key focuses again, is to help through things like lean and tools to make their day-to-day lives much easier to manage with reduced stress, less firefighting, better information flow. ‘Cause that's part of their challenge is getting the information in a timely manner, communicating it to the patient, working with the REI, to support them on adjusting the patient's medications, for example.

So the more that you can do to reduce that stress and the time constraints that they have. Again, the better it is for them. So yeah, absolutely not. That comes in with the proper integration with, with EMR. For example, one of the key things that we're ensuring is a very thorough integration between our say our testing end points, whether that's in clinic or it's external that the test requisitioning and results immediately flow in an ideally you would have that kind of augmented AI that could say, okay, given this test results, here's the recommended adjustment, the idea of 40 and you can look at it and say, yeah, that makes sense, get the okay from the REI and bang it's done. So you can have a lot more that decision-making that goes on. Be augmented and not fully automated, but at least augmented to speed up the process. 

[00:47:23] Griffin Jones: Maybe we'll get there in the cup in the next couple, in the next decade or so I want to give you the thought to conclude about however you want about lean and in the fertility field.

And what you want to see happen in the next couple of years, but we've been talking about EnagedMD for those of you that our managers and, and nursing managers, this is something to bring to your superiors. This is something that. It's worth a little bit of political capital from you. And you can use this episode to do that.

If you say that you heard it on the show or heard it from me or heard it from Steve on the show, then they can get 25% off their implementation fee. But it's really for making sure that you're not losing any more nurses, making sure that you're not having patients lights you up on online reviews because you're just so slammed with capacity and providing some relief at a time where it is. It is hard to relieve the workload that your mid-levels and nurses and other staff are, are dealing with. And if you're a practice owner, it's more likely than not that you're already using EnagedMD and maybe we're preaching to the choir, but if you're not, then now really is the time. And so Steve, I'll let you conclude on how, whether it's EnagedMD whether it's Lean whether it's just what you want to see your vision for the field for the next couple of years. 

[00:48:46] Steve Rooks: Thanks, Grif. I mean, for me, the key thing is finding ways to innovate that bring value to the patient that really improves their understanding and their feeling of control over the process and doing it in a way that helps also realize productivity gains across the value stream. And to me, EnagedMD is a great example of that where it provides much greater education and to the patients. So they understand better.

They're more in control of understanding the decisions that they need to be that ties into the informed consent. And more importantly, we easily justified implementing EnagedMD from just the savings of the nursing time for the education and for walking through the informed consent forms and signing off, it was, it was one to me, it was one of those, no brainer decisions.

The savings alone easily covered the cost of implementation, but more importantly, it was an ant situation where we were really adding value to the patient journey through the better education, through the better understanding for the benefit of a much more effective first consult and I'm follow on and engagements with the, with the REI.

So to me the kind of tools that we're looking to implement are things like EnagedMD, other examples, another source of challenges for patients is really understanding and setting the proper expectation that IVF in particular could easily be a multi-sectoral journey for them.

And I would, I can't tell you the meaningful percent of patients that don't quite understand that despite the REI attempt to explain that given their circumstances IVF could be a multi-sectoral journey. And we're investing in tools that helps visually explain that better. So the REI can using the visuals, help them better understand that for them IVF could be a two or three cycle journey as opposed to getting pregnant the very first embryo transfer, which can happen, but it's very rare. So those are getting the examples of having tools that really add value for the patients, but help improve the REI, his ability to explain and help them make the right decisions for their benefit.

[00:51:04] Griffin Jones: Steve Rooks, you are a true chief operating officer. You are a true systems-thinker. It is the way that your brain is wired. Thank you so much for sharing some of that brain on Inside Reproductive Health. 

[00:51:17] Steve Rooks: Thanks very much Griffin and I really appreciate it. It's been an honor to actually be on your podcast.

I really appreciate it. 

[00:51:24]Griffin Jones: My pleasure.

134: What the Heck is Kindbody Up to Next? with Gina Bartasi

This week, Griffin chats with Gina Bartasi, founder and chair of Kindbody about the development and success of the first-ever consumer fertility services brand. Griffin posits that their latest acquisition of Vios will not be their last, Bartasi disagrees and instead has her sights on global scaling. Bartasi believes that the end-to-end care model of Kindbody is most beneficial to the patient, and everything is better, and more efficient, under one umbrella.

Listen to hear:

• How Kindbody developed their brand, and how it influences their culture for employees and patients alike.

• Griffin press Bartasi on future multi-site multi-practice acquisitions, and how that may influence global growth.

• Where Kindbody stands on utilizing extended care practitioners for retrievals and transfers.

• Bartasi argue that Kindbody’s end-to-end business model improves (and controls) the patient care experience.

• Bartasi use stats to back the clinical success of the Kindbody model, despite the 25-30% price cut.

Gina’s information:

LinkedIn:https://www.linkedin.com/in/gina-bartasi/

Twitter:https://twitter.com/WeAreKindbody

Facebook:https://www.facebook.com/kindbody/

Website:https://kindbody.com/

---

[00:01:08] Griffin Jones: The first global brand in the reproductive health space. And if you think there's been global brands before listen to this episode, because I'm talking about consumer brand, this is the first global consumer brand in the reproductive health space. It's Kindbody. I've got CEO, Gina Bartasi back on.

After a couple of years, we talk about what Kindbody has been up to in all the markets they're in and where they're going, talking about the history of their acquisition with Vios, they've raised tens of millions of dollars in venture capital funding. There's a couple of things that I pushed back on Gina about talking about this concept of this Jeff Bezos, Amazon Sam Walton, Walmart type of end to end channel domination. They Kindbody is going after. There's a lot that I'm not qualified to examine. I'm not qualified to examine on a lot of their business model and certainly not the clinical side. And I know that a couple of you are going to think that I'm kissing rear end when I'm, when I talk about brand, when I go into that part of the I will fight you. I am not kissing any, but I am telling you the things that I've been telling you for years, and I'm seeing somebody do in practice and now people are starting to feel, oh, this isn't just about bringing new patients in the door. This is what it means. To have a brand that is not window dressing.

If you think that Kindbody’s brand is, oh, that's just good marketing. That's just pretty stuff. It isn't, it's the foundation of everything that they've been able to put together. And it is an extreme, competitive advantage in recruitment and retention of employees among other things. So if you'd like some help with that guest who does that for us?

The firm that sponsors this podcast, of course, Fertility Bridge. And we are helping a lot of different practices across the country to up their brand, regardless of whether they have a patient acquisition challenge or not many of you don't, but there are reasons why this branding and creative messaging really, really benefits groups.

And we talk about that today. So you can tell me if you feel that I was kissing her. If you feel that I was too tough, you let me know, enjoy this episode with Gina Bartasi.

Ms. Bartasi Gina, welcome back to Inside Reproductive Health. 

[00:03:40] Gina Bartasi: Thank you. Thanks Griffin. Nice to be with you. 

[00:03:43] Griffin Jones: What is it Kindbody been up to in the last two and a half years since we spoke, nothing right?

[00:03:48] Gina Bartasi: Nothing, not anything at all. 

[00:03:50] Griffin Jones: Not a damn thing. 

[00:03:52] Gina Bartasi: Sitting, twiddling our thumbs, trying to figure out what we're going to do next.

You know, I've always said the success of any businesses, only about its people. And so we have an extraordinary team. The team has parlayed their knowledge and experience into a tremendous amount of growth. Right? So today we have 26 locations not the least of which is the new virus clinics that will pull into the Kindbody network that acquisition closed February 1st.

And then those Vios locations will be rebranded Kindbody. But Angie Beltsos is one of a kind you know, I know that the audience is aware of all the PE money rolling up practices in the industry. We are not a roll up firm. We have preferred to build de novo, but Angie is unique. She is extraordinarily talented as a physician and she is even more talented as a clinical leader, just as a leader in general, she knows a tremendous amount about business, about productivity, about margin.

And so, yeah, we have 26 locations. We'll be adding another 10 this year for 36 locations by the end of the year. And then we're back in the employer business. So we see quite a bit of interest from the employer business. Certainly our consumer audience that we started with is still a big part of our revenue.

And then we see quite a bit of payments come from the managed care industry.

[00:05:15] Griffin Jones: She  knows the answer to this, but I don't, is Vios the first acquisition that kind of body is done in terms of presence?

[00:05:21] Gina Bartasi: I noticed the first acquisition, I've done quite a few acquisitions in my career, but it may be the first one at Kindbody.

I shouldn't, it should be an easy answer. We haven't bought any other clinics. I'm trying to think if we've bought anything else, I guess not. So Vios is the first, it will be the last multi-site multi-physician practice we acquire again, we prefer to build de novo. We wouldn't rule out some of.

[00:05:45] Griffin Jones: This podcast lives forever Gina, do really want to say that it will be the last. 

[00:05:49] Gina Bartasi: No Griffin, it'll be the last multi-physician multi-site acquisition we make, we may make some tuck-in acquisitions. Right. 

[00:05:58] Griffin Jones: But even that, why rule that out?

[00:06:00] Gina Bartasi: Because I know the multi-site physician groups and they are already owned by one of our peers that are not a lot of multi-physician groups, still standing that are independent, there's probably less than 10 in the entire country and the 10. 

[00:06:16] Griffin Jones: All multi-position and multi-site meaning multi-site meaning more than one lab. Is that what you mean?

[00:06:22] Gina Bartasi: That is exactly right. That is exactly right, because we wouldn't be interested and it's too easy. Thanks to our extraordinary real estate team for us to stand up a clinic with the lab. They've gotten very proficient at it in the last 12 months. So the reason we would make a multi physician, multi location acquisition is to get scale. There is not, again, there's probably less than 10 of those.

So yes, there are multi-physician, but maybe they only have one lab and then one satellite office, which would rule them out. So that's the reason it's an emphatic statement. I think, you know, we're getting a lot of requests now. From the employer market to think about international expansion and so potentially internationally, we wouldn't rule it out, but in the United States you know, and Angie knows everybody as well.

We are looking for physicians that are like-minded, you know, Angie, she's wildly unique. And so she's amazing, and we have so many other amazing physicians, but there's a culture at Kindbody and Angie believes in that culture, the culture was almost identical to what Vios culture wise. I mean, we prioritize patient care.

The patient always comes first. Our employees come first, you know? And so there was this, this real foundation and we are here to serve others. And so that's what makes, it's one of the things that makes Angie and Vios so unique. And it's also the reason. I think we're limited in terms of other potential acquisition targets is rare to.

So, seamlessly be able to put two companies together that agree on so many things. Usually when you're rolling up things or you're putting two things together, there's a lot of friction. The integration is hard. There's a lot of disagreement. There's a lot of debate about, oh, and you just don't have any of that.

You just don't have any of that. We are incredibly like-minded now we've known each other a decade and that probably helps as well. 

[00:08:19] Griffin Jones: Well, I want to ask about how you did that vetting because it sounds, it reminds me a little bit of like the Facebook, Instagram, sorry, where Zuckerberg said you, most of the time, we're not going to do.

Acquisitions most of the time we're going to be building out Facebook property now, meta properties. But at the time they saw something that was perfectly in line with what they were trying to do. They stole Instagram at the time for $2 billion and it totally fit. And so that's what you were describing with the Vios acquisition, but how did you vet it to that point?

[00:08:51] Gina Bartasi: Yeah, again I think knowing Angie and Greg for more than 10 years was extraordinarily beneficial. We had talked on and off for the last several years. Again I've thought Angie was just as unique as I think she is today. I thought that the first time I met her at 10 years ago, I met her at PCRs and she's so articulate.

She listens first, most leaders talk first and listen, second, Angie listens first and talk second. And that's a rare characteristic to be both a leader and an extraordinary listener. A lot of leaders are not as humble as Angie is. Angie is extraordinarily humble. And so I would watch her in meetings.

I would watch her interact. I was like, wow. She is a total bad-ass and I always wanted to work with her. I did work with her. I worked with her at Fertility Authority. I worked with her progeny and as time grew on, the affinity grew more like she, she continued to impress me. And she continued to raise the bar.

I knew her when she was at FCI, I watched her grow Vios she does everything with a tremendous amount of elegance to and class. And that's hard to do. It is really, really hard to scale a business and grow a company that fast and keep your cool and take the high road and work hard and not lose it while you're trying to juggle all these things.

And she just did it, you know, and I watched her. And so anyway. 

[00:10:18] Griffin Jones: She does do that by the way. No, I don't talk about things that happen in business meetings on the air, but Dennis, at a super high level, I think Dr. Beltsos is comfortable with me saying she does that. We'll be quiet and let everybody talk and then she's, and then it's like, all right.

And then she's honest, like she lets people say it and you get to see your processing and then boom she's she's got it. So you described her well, so that got you into the Midwest. So you, you found this really good culture fit for you all you acquiring Vios and then, and now you're in the Midwest.

What cities are on the, the docket that you can tell us about now?

[00:10:54] Gina Bartasi: Yeah. Well we want to be completely transparent, so we don't mind sharing with the audience, but we're opening Seattle. We're opening Dallas, Houston, orange county Miami, Charlotte we're opening in Washington DC next week. Two weeks.

May 4th. Whenever that is. Oh, maybe it's in more than two weeks. Maybe it's in three or four weeks. What am I missing? Should be like, we've opened two already. We opened Denver two weeks ago. We'll open Dallas in three weeks. Excuse me, Denver. What did I say? DC? Dallas. Houston. I'm missing some, but anyway, that's kind of the footprint.

Oh, we're opening Brooklyn, a third location in New York. I should have the map in front of me, but that gives you a general idea. 

[00:11:35] Griffin Jones: It gives me an idea of the near term is, I mean, in a few years time, are we talking about everywhere? Gina? Is that the play? Like, are we going to see Kindbody Cleveland? Are we gonna see Kindbody Buffalo?

Are we going to see? 

[00:11:46] Gina Bartasi: Columbus, we're actually coming to Columbus before we're coming to Cleveland. We are, we're taking and we're adding a location in the east bay. So both New York, San Francisco and LA we'll all have three locations, but I think that's right. Our plan calls for 50 locations within the next two years.

We want to be where our patient population lives and works. The majority of those locations will be retail in nature. We, you know, believe in the consumerism of healthcare and really building a global brand. We talk about a national brand, so our eyes are set on the US over the next 24 months.

But in three to five years, I think you would see con body locations internationally as well. 

[00:12:25] Griffin Jones: I want to talk about that global brand and what Kindbody is done to get to what you have now. I am jotting that down because I want to ask you a little bit more, but I don't know if the employer benefits side was part when we spoke a few years back on this show.

And so what has changed in, in employer benefits from, from when you started Fertility Authority and then, and then progeny that or whatever, what was that? Seven years ago or? 

[00:12:53] Gina Bartasi: Yeah, seven years ago. 

Yeah. 

[00:12:55] Griffin Jones: So what has changed since then that you feel like, okay, we need to be a part of this? 

[00:13:01] Gina Bartasi: Yeah, I think the biggest thing that's changed is employers now recognize that having a fertility benefit has gone from a nice to have to a must have today there is a robust RFP process.

There wasn't any RFP process. There wasn't anybody to RFP the business too. It was kind of progeny. And then I think you had some legacy players whether that was when or arc, but they really weren't in the employer business like project. You had no competition the first four or five years, and then they've got their hands full.

Now in the last couple of years, there are several kinds of other Progeny me toos, whether you, whether you, you know, again, you see Carey C store club, you see Maven coming in and there they do care navigation. We sit independent from those folks because we're in the provision of care. So we can also do care navigation, which we would argue as table stakes, but really only three things matter in healthcare.

Any kind of healthcare, but specifically fertility 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, you cannot effectuate change in those three areas, an insurance company, or a 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 a 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. I think in the beginning 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 it again, it's moved from kind of a nice to have to a must have benefit.

[00:15:13] Griffin Jones: For that reason though. Wouldn't those other companies say that Kindbody is not independent, that they're independent because they're not in the provision of care and that you're able to manipulate the market. If you end up becoming the Jeff Bezos or the Sam Walton. out there. 

[00:15:32] Gina Bartasi: Yeah, well, so we have partner clinics who are very like-minded. We have other clinics that are not like-minded and they don't join our network, but there's a bunch of clinics that prioritize patient care and are very genuine about patient care. And they see a lot of volume from us now, a lot of volume from us.

So I think that concern of okay, if Kindbody sells and directly to the employers, they're going to keep all the business. We have too many other partner clinics willing to attest that that's just not the case. I think in the beginning there was worried, but we've been at this, you know, a year and a half, almost two years now.

And we have clinics again, that would attest to Kindbody treats is fairly, they pay well, they pay on time. Like there's just too many people out there advocating exactly the opposite. Now our job is to continue to improve member experience every step of the way. And so you know, we prioritize patient experience and we do think we hear from patients the way patients experience and go through that Kindbody journey is very different than many of the other primarily legacy practices.

There are some new clinics, again, that I think are again very like-minded in our peer group that we have a lot of respect for it's mutual, but going through. Kindbody utilizing our proprietary technology is a very different process than a legacy clinic where you fill out a paper chart, the nurse calls, you get your voicemail, you get to call them back.

They get to call you back. They get like all of that waste and inefficiency and telephone tag. That's endemic in the legacy fertility programs, as well as the legacy care navigation from secure navigate. The challenge with the care navigation firms is, you know, once you refer that patient to another clinic, you lose sight of them.

You don't even know if the patient showed for their appointment, much less, whether they had an ultrasound scan and for the employer that they don't even know if they're being double billed, they may have major medical and you could build that for them. You could build the ultrasound scan through major medical.

You could also build the ultrasound scan through your fertility care navigation firm, but there's a lot of waste in healthcare and in the fertility industry that we seek to continue to get rid of and, and operate more efficiently. And I think the employers, and I know the patients see that today, the member experience is significantly different and I use member and patient as the same thing.

Patients are the consumer terminology member is what employers call their consumers or their employees are called members. 

[00:18:02] Griffin Jones: So how do you scale this out at a, at a time when REI is, are a bottleneck with 1100 of them in the entire country, we have far more people that need treatment than we have an infrastructure to be able to treat them.

And so how. Are you able to expand how many people are able to be treated? What's the role of OB GYN is, or physician extenders in your model? 

[00:18:30] Gina Bartasi: Yeah. You know, I think everybody acknowledges today. You have to have a physician extenders. You just do there's, more than demand than supply.

And the number one thing that hurts a patient is having to wait 3, 6, 9 months for treatment. I would tell you that again, Angie Beltsos says, your question is about scale and how we serve up enough REI is to handle all of the demand that is Angie Beltsos's wheelhouse. You look at the physician productivity of her doctors and it's extraordinary.

One of her lead physicians did more than 1000 cases last year. That's extraordinary. Now you have to have the mindset. You have to have the support around you. You have to have the APP's around you. You know, again, I've spent 12 years in the industry and most doctors, not most, a lot of doctors I've talked to are very comfortable doing 150 cases.

And they say that, listen, I do 12 to 10 to 12 cases a month. I sell an IVF cycle for $25,000. And that's my model. I'm like, okay, well here, our success rates and heres, yours, and I just don't think patients, we have one mission and that is to increase accessibility for all. Fertility treatment has been reserved for rich white people on the upper east side of Manhattan.

 And the Bay Area and Beverly Hills, and we think there is something tragically wrong with charging $25,000 for an IVF cycle and insisting on cash pay. We think the model has to change. You have to bring down the cost of care. You can have a premium experience without a premium price tag. Griffin.

The question is, how do you do that? Well, you utilize technology and you use technology to replace everything that's transactional and healthcare scheduling appointment. We are the only fertility clinic that I'm aware of that allows you to schedule an appointment, move an appointment, cancel an appointment.

You can pay your copay. Like everything. That's transactional should not be done by an REI. It should not be done by your front desk manager. It should not be done by your RN. It should not be done by any of those people. It should be done by technology. How do you pay for everything else? You do it online.

Like this industry is incredibly archaic that there's all this telephone tag in doing simple things like paying copays and scheduling an appointment, or even hearing your medication. Like you're walking down the street, you're driving and a nurse calls and says, turn up or down your FSH drug. And you're trying to write and drive and you're, you know, it's incredibly emotional, like all that's bad.

So we own our own patient portal in our EMR. So everything's incredibly transparent. You can pick it up. And by the way, if you forget what the doctor said, you can go right back to your patient portal and remember what the doctor said. So we believe that we can get to scale and extraordinary physician capacity, but we have to have like-minded physicians, the physician that says to us.

I only want to do 10 to 12 cases a month is not the right fit for Kindbody. And if Dr Beltsos says we're on this call, she would say the same thing. And that doesn't mean that we want the physicians working harder. It does simply mean we just want them more efficient instead of taking down the patient's credit card or calling the patient's insurance company to help them understand why same-sex male couple cannot conceive and, and meet the 12 month threshold that your legacy benefits provider has in place.

Like all of that needs to go away so that the REI is doing things only the REI is capable of doing. 

[00:22:05] Griffin Jones: So I've got to decide because I'm not Joe Rogan with a three and a half hour format that I've got to decide, which of these four or five sub topics that I want to go down that you talked about. Let's start with the, you know, talk about like, we agree that we're at a point where we have to use advanced providers.

The debate is to what extent. And I just had the CEO of Mate fertility on debating this topic with Dr. John Storment and I don't know if that episode will drop before or after yours, but th but it's very much a debate of to what extent. And so what is the limit of, in your view of where advanced providers can be used or where trained non REI, OB GYN?

[00:22:50] Gina Bartasi: So you should know that I do not make any clinical decisions. I have never made any clinical decisions. I don't make clinical decisions today. Dr. Angie Beltsos our CEO of clinical. We'll make all of those decisions today. We use REI to do all retrievals in all transfers exclusively. Okay. Now we people know Kindbody and the knock is, oh, you guys have OB GYN.

Well, 20% of our revenue is GYN. We do complex GYN, right? I mean, again, what, what, what we don't-we prioritize the patient. Okay. We just do, and we think when you have an ectopic, the worst thing we can do is send you back to a primary care. Or if you have a miscarriage, the worst thing we can do is send you back to some doctor that doesn't have your medical record to go back and do a surgery that can be done by our OB GYN onsite.

You build an affinity with this brand and this REI doctor, you hear patients talk about autonomy. My fertility doctor, now I have to go back to my primary care doctor to get a D&C, like something's wrong with that? That's archaic healthcare that has all these silos and bifurcation. And no one cares about the patient.

Do my medical records follow me from my primary care, from my OB GYN, to my REI, to my mental health specialists, to my nutrition coach. The answer is no, unless you're at con body at Kindbody. We built the entire company around the patient and we said, okay, we're going to blow everything up. We agree that the current model is broken.

It's not anybody's fault. It's just history, right? That's how it was created. The REI set over here and the primary care it's because of how insurance pays for historically didn't cover fertility, but yes, covered major medical and maternity. But today, again, if you prioritizing the patient, the patient doesn't want to be shuffled to all of these different providers.

They just want a baby. They want it as affordably and as nicely and as kindly and as easily and conveniently as possible. And it's not that hard, but it does mean like breaking some traditional rules that says, okay, your OB GYN and your REI cannot be under the same roof together. We think that's silly and not patient friendly.

[00:25:11] Griffin Jones: Well, you talked about as part of that, that you're not going to make these clinical decisions. That's why Dr. Beltsos says she CEO of clinical. And I have to say I'm incredulous when CEOs say this a bit, because to me, it's not like there's not a perfect divide in everything. There's things overlap a bit.

And an example that I was challenging Dr. Andrew Meikle, on this from the Fertility Partners and how he gave an example of client is kind of like one that you talked about that happy doing 150, 200 cycles, the sweetest, sweetest people that really love their patients are definitely not charging them a lot.

Definitely they are below market rates. This individual sees all of their own you know they eat this individual does the ultrasounds for all of the patients. And like to me, that's where, you know, when you're saying like, you know, we'd get rid of these transactional things that the REI does not need to be doing.

That's something that the REI does not need to be doing in my view business guy, Grif that owns no part of his business, but if I own part of someone's business, I think that I would be making that call. And that's an overlap where the standard of care matches with or overlaps with the transactional, isn't it?

 Is a light bulb starting to go off about what branding really is, what its power is that it's not just a marketing tactic done by your marketing director. It's not just done for patient acquisition.

It involves the binding of the culture of what you're able to do, of how patients perceive you and how they want to come along and how your peers and prospective employees and prospective providers. See you, and are you the one that is in line with the current generation? Can you at least communicate to them or are you seeing as something less relevant, something less?

To want to be a part of, if that's the case, did you know that we have a full creative team? We have a creative director, we have an account manager, we have an operational marketing strategy. We have a digital strategy, all full-time people. Plus our production, people that know the fertility, patient marketing journey of not just the creative messages.

But where it goes and have a system, a fertility brand scale that makes it easy for you to not see, okay. It's just us trying to say we should become more current or more hip, more new, but that can actually say, okay, this is where we are at a 1.75. And this is where we want to be at a three point six. We have that all, we have that all Fertility Bridge and to start with us, we're not going to do everything for you at once, but just to look at what you've got and at least tell you what to do.

That's less than $600. It's the goal diagnostic. It's 90 minutes with myself, us giving you this framework and going through what you have and applying that discussion of positioning and branding with you and your partners go to fertilitybridge.com. Sign up for the goal diagnostic and represent your group in a way that is fitting with the practice that you're really trying to build, because I think you might be starting to see that all this brand thing it goes beyond just getting people in the door.

It's who you are. And if you want some help, we're happy to help you with it fertilitybridge.com goal diagnostic. Meanwhile, enjoy this conversation about branding with Gina Bartasi.

[00:28:46] Gina Bartasi: Well, so again, this has to go, this goes back to why Vios and Kindbody were so meant to be like the way that we were practicing medicine. And we thought about ultra sonographers doing ultrasound scans was that's how we were practicing medicine with Vios and Angie, and decided to come together, like how we practice medicine and how we prioritize the patient, how we have phlebotomist draw blood sonographers, do ultrasound scans.

You know, like what nurses do we was just together. Now I will tell you, Angie has upped the game. She's refined the process and we follow her lead. There is no, like, again, an Angie will be the first to say that. And the business people take a back seat and Angie is a business person, but she is our clinical leader.

So she decides patient flow, a number of nurses to REI. She decides all of that. Now, again, the reason that these companies came together so easily, We believe so many things. We were already practicing medicine. It's not like you had to take the client that you just mentioned that was comfortable doing 150 cases a year.

And you had to put that culture with this culture. The cultures went together just like this easily and seamlessly because we already agreed that truthfully, the REI is a subspecialist. This is a well-educated they've been in medical school a very long time. I have a hard time asking any of our REI's ,can you do an ultrasound scan? They'll they will do it. They're happy to do it. They've done it before. It's just, you know sonographers doing 20 ultrasounds a day and REI might, you know, do two a week to help one out. So it goes back to, you know, again, patient how the what's in the best interest of the patient.

Do you want somebody doing this twice a week or 20 times a day? 

[00:30:43] Griffin Jones: Well, let's talk about the best interest of the patient with regard to what you were talking about. Like you said, you know, what Dr. Beltsos has been able to do with physician productivity is incredible. I was just talking with just recorded a different episode, different topic.

We're talking about embryologist and it was like, these embryologists are burnt out. Like they can't do any more because, but the demand is that, like, we were trying to get everything we possibly can out of these embryologists. And so there is a tension between what the market needs, the patients need that you're trying to address and what the capacity of the workforce is able to deliver.

You said in the very beginning, something that I don't like when CEOs say Gina and I, cause I try to make myself choose, which is employees come first patients come first, which is declines come first or new employees come first. Do the managers come first? Or the customers come first. And so what, what, like when you're trying to meet a demand and meet the market, and we know that the market demands five times more than what the field's putting out, you're trying to meet that.

How do employees possibly come from first? 

[00:31:53] Gina Bartasi: And 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, 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. Listen, there's a shortage of labor everywhere.

It's the embryologist, there's a shortage. We know there's a shortage in our eyes. We have to do a better job of training. We've been fortunate, you know, we pay competitively our team members get equity. That's not true for 90% plus of the fertility clinics. And so I do think it was really, really difficult for us to hire the first 12 months, but in the last 12 months there's quite a bit of incoming interest in I've got career opportunities at Kindbody.

[00:33:00] Griffin Jones: So then how, but I used to agree with the employees always come first and I'm trying to like, like actually live that out now. But I used to believe that Mark Spolestra said that we have it wrong, that we put shareholders first, then customer second and employees last, and it should be employees, customers, shareholders, because if you take care of the employees, they'll take care of the customers and now it'll make the shareholders happy.

 And I always did believe that until like, but what about when you get to this point that we're at, which is a bit historic, like this labor shortage that we're seeing, not just in the IVF, like every place in the market, but it's like, all right, I can take care of employees till the cows come home.

Anybody's employees can go someplace else. Right now. You're trying to, you're trying to keep them up. And meanwhile, there's so much money in the marketplace that people are coming to you and there's so much demand. And you're trying to like, how do you do that now? 

[00:33:54] Gina Bartasi: Yeah. I think again, you have to utilize technology, so you have to go through the lab.

Certainly. That's what we're doing in practice management. So our product people, shadow doctors and nurses to see what they do on a daily basis. That's repeated. Okay. What do you do every single day? That's repetitive. That should be moved to our EMR patient portal or somebody else now what needs to happen that we're probably not doing as good.

A job of Griffin is having our product. People shadow the people in the lab and it has to do with the sterile nature of the lab it has to do with I'm not even sure what it has to do with you know, Dr. Beltsos could tell us, or even Dr. Morbeck Dean Morbeck as our chief scientific officer. But we have to get arduous task and any task that can be moved to technology, to technology, and then you free up human labor.

We've been able to do that on the practice side. We have not spent as much time refining that on the lab and embryology side. I'm optimistic that more economies of scale can come. If you just spend time in the lab and say, what are you doing? That's repetitive. That should be moved to technology.

I do know now we've rolled out some new technology platforms to help kind of ease the burden. And then there's this, like, there's a, there's a training and an input of data and an expert and an export of data that is more time consuming for our embryologist than we would like. But you get through this kind of crunch time of about three months, anytime you roll out new technology or implement a new SAS solution, but we are constantly thinking about.

How we can use technology, whether it's our own or whether it's a third-party vendor to free up humans in this case, embryologist. But right now, embryologists are doing a lot of repetitive things that we think that can be moved to technology. Now, right now they're still biopsying, trifecta, derms, like a lot of their stuff.

They're still you know, cryopreserving oh, sites, they're still doing a lot of things that require extraordinary hand-eye coordination. And those things are, are not close to being automated. But there's still a lot of other things on their plate that can be automated. 

[00:36:07] Griffin Jones: Well, let's shift gears a bit and talk about what I really want to talk about, which is this global brand, cause this is the type of stuff that I am interested.

I am interested in brand. I'm interested in creative messaging and I think it is a huge mistake for anybody who thinks is window dressing. That is not looking at it at all correctly. And I want to know if you think that. Maybe exaggerating with this, but I don't think that kind of body could have gone into all of these different angles to the depth that you have without the foundation of the brand that you had built.

Am I overstating it? 

[00:36:48] Gina Bartasi: No, but you're a marketer and a brand guy. You sound like me. Like again, we knew it's not fertility, it's not IVF. It was intentional Kindbody wants us as humans to be kind to our body. It also does not uniquely say IVF. It could be egg freezing. It could be same sex. Like there's a lot of things that go into this name and this brand.

And it doesn't say Seattle, it doesn't say Charlotte, it doesn't say any particular city can be a global brand. But we thought about that from the very beginning, because I felt like healthcare was missing a room. Global brand. It's not blue. It's not pink. It's, you know, yellow, we call it optimistic, yellow, yellow is intentionally gender neutral.

A lot of people, if you do all of these customer surveys, which marketing people do a lot of people, don't they just say, here's what I believe. And I'm like, whoa, did you do any research or did you do any customer surveys? But if you do customer surveys on your thoughts about yellow, lots of people associate yellow with happiness, right?

Hope like there's a lot that goes into this yellow and this name and it's intentional. All of our locations is intentional. Do we don't have any hard edges in any of our clinics? There are no 90 degree desk. Everything is round there's again, a lot of thought that goes around this round desk, softening the edges.

There are no medical degrees on the walls. Our REI are highly educated. We don't need degrees from Brown University or Stanford on the wall. You'd probably as an educated patient, know that I went to Stanford or to I didn't. But so we do, we believe there there's huge power in brand and now, you know, We've been fortunate.

There's a lot of affinity for the brand. And so now we try to, we're always working to extend the brand. And so now we are, you know, we spray paint chalk every time we open a location, it's cool to be kind. Right. ‘Cause we have to remember in this busy world, and this is before the war and now there's a war and there's, you know, there's just a lot of challenge.

And so we have to remind people because it's cool to be kind like lead with kindness because kindness is contagious. It's like our yellow happiness, like, you know, just be kind you know.

[00:39:01] Griffin Jones: Brand driven CEOs have such an advantage that you being a brand driven. Like when you look at like, I think Sara Blakely, Spanx, Walt Disney Richard Branson, like these are brand driven CEOs and to you are Kindbody is the furthest end of the spectrum.

I actually have that spectrum, but the other end of the spectrum is people who think nothing about brand whatsoever and say, oh, we have to, oh, that's like a logo, a yeah. Like colors. Yeah. Like have our marketing director just, just do something like that. And it is everything that you do, and it's enabled you to go to, to all of these different places.

 And so I want to talk a little bit about like, how that. Moving along with the generations, because, so we made a scale, we made a four point spectrum of the fertility brand and decide on a one. This is your advanced reproductive surgical associates of Smithfield like that, the ones. And then the twos is like Patel, Fertility or, you know I'm trying to make up a Smithfield IVF, very on center.

And then a three is like the nicest of your healthcare brands got a familiar messaging and, and kind of body is the, is one of the only, so we ranked every center in the entire us and Canada kind of body is one of maybe like the only force they one or like one to three fours. And so that, like, you're the first kind of consumer brand in this space.

Talk a little bit about. 

[00:40:42] Gina Bartasi: Well, that's intentional. Right? First of all, thank you, Griffin. Second of all, it's intentional. It didn't come after the fact it was we wanted to create a consumer brand, by the way. You know, we also think now, like, and I know Peloton has been beaten up in the public markets, but we think about Peloton instead of soul cycle.

Like, we've talked about how magical Dr. Angie Beltsos says like, how can, how can we get Dr. Angie Beltsos to be Ally Love or Robin Arzon Jess King? Like, how can you, how can you make Dr. Angie Beltsos global, right? And so we are constantly thinking about the brand and about how we protect the brand and how we continue to do right by the brand.

How even in the most difficult, challenging situations, we're kind to each other kind to competitors. We call them peers. Peers is a more friendly term than competitors. So it's in our language, it's in our culture like how we protect each other, how we protect this brand, how we cultivate the brand.

But again, it was very intentional from the beginning when you come to any of our clinics, or even if you go to the patient portal, most patient portals are ugly. Most EMR is, are ugly. Everything when we should, at some point give you a product demo. When you come in to our product through the technology, everything is very elegant.

Everything is yellow. It's on, not everything is yellow because we have neutrals and other colors, but it is aesthetically pleasing, right? And so you can see all these touch points along the way. We predict your likelihood of success. We predict how many eggs we think you're going to get. We predict fertilization rates.

We show your embryos growing. We are completely transparent. And again, when you go into the clinics it's not white, right? There are no white coats. There are no white walls. There's no white paper. 50% of our REI's are BIPOC. I am incredibly proud of that because guess what? Our patients are 43%.

But it goes back between 43 and 50%, but it's intentional. If you really create a mission that says, we want to increase accessibility for all, then you have to have a brand. You have to have visual elements. You have to have clinics that look and speak to accessibility for all. And that's not white walls or white coats or white paper. 

[00:43:08] Griffin Jones: It of corresponds with the generations too.

So on our scale, we laid it across the generation. Like, so you picture the generations is like a news ticker, and it's not that a one was, was like one equals baby boomer. It's just that like the overlay of a one is that it was designed or, or lack of design for the baby boom generation. And a two was that baby boomer bit X and three was mostly acts a little bit millennial. And so the fours, which you're one of very few as is the the first brand that's for millennials and gen Z 

[00:43:49] Gina Bartasi: Yeah. Yeah. Again, a large portion of our new patients come from Instagram, look at Dr. Beltsos or Ruby Jelani or any of our doctors. And, and we encourage them to do that.

Like we are kind, but we're also fun and competitive and we're like, okay, who can, you know, create our competitions? Like could be great. The funniest Tiktok video, like, I don't know, we're having fun, practicing medicine, helping our patients build the families of their dreams and that doesn't have to be white and sterile and old, right.

It can be fresh and it can be fun. And so, you know, when we think about brand, we have competitions of who can create the most fun tick-tock video. The majority of REI is that got your one, two, and maybe even some of your threes are like Tiktok, like, is that tic-tac-toe what is Tiktok? You know? And so, but we are constantly thinking we want to be better than we are today.

All of us do. That's the competition in us. Okay. We have an extraordinary brand today. Like how do we take it up a notch? And we're trying to think about what's happening new on, on Instagram. And do we call our locations like as a con body ATL, is, is it Kindbody Bay Area? Do you start then to segment these markets or is it just one brand?

But we think about brand every single day. We think about culture every single day. 

[00:45:14] Griffin Jones: Talk about how those two are, are together, because I'm trying, I'm just finishing an article called the difference between Brandon and called where they, where they converge and where they diverged. And so I think like so many, I'm finally starting to get people interested in branding and creative messaging for like how they set expectations with their patients and how they get their team to be cohesive around something, as opposed to, they don't care about patient acquisition right now, because everybody's slammed.

That's how I started in this marketing field was marketing patient acquisition, but it's like, no, this is how you get people and like it as a part of something. So I want you to talk about the culture, cause I'm thinking like Gina, before I look at somebody's LinkedIn profile to like, see what they're, I know that they went to work for cause it seemed in the yellow, in the background.

And so talk a bit about how you use the brand for culture. 

[00:46:12] Gina Bartasi: Yeah, I think a lot of it starts with humility, right? The brand is humble. It's not, anybody's last name. It's not, you know and our culture really starts with this humility. Right? So those two things are ingrained. I think that's not just humility too.

It's a vulnerability to it. You know, it's also our brand and our culture. We do embrace risk. You know, we tell our doctors so I can brace risks, do something crazy on TikTok. And you tell a doctor or a scientist embrace risks. 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 risks.

When it comes to a prognosis of an onco patient, we're talking about taking risks 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 I think the other thing that I would say about culture and brand is team, right? I think too often, you know, healthcare, people and doctors in particular may think solo first, like I'm a doctor and at 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 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 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. 

[00:48:15] Griffin Jones: And with recruitment too, I have to believe that that's giving you an edge because just look at, you, look at a one baby boomers. Who's answering your phones. Who's not even the answer who are the docs now who's buying in. And so I have to believe that, you know, it's like in these places that are like, oh, you know, we're busy as can be with.

New patients, but what is it like with people that like, do they want to come work for you? Like are they excited about, are they behind a mission together that they will go and express to their friends of like, this is who IVF and worked for and you better know about them. 

[00:48:53] Gina Bartasi: They are. And they do.

That's recent though. It's just in the last 12 to 18 months. You know, Dr. Lynn Westphal was our first REI and our chief medical officer. And it was hard even with Lynn's reputation and, and she has an extraordinary reputation and is a member of SARC, a legacy member of A\SRM and starting a phenomenal reputation.

But remember doctors I said are notoriously risk-averse. You encourage them to take risks and not like, whoa. And so in the beginning they Kindbody was, you know, another startup and, you know we started in a mobile clinic that was oriented towards the brand and service. We're going to bring care, whoa, Griffin, we're going to bring care to the.

You don't have to come to me. I'm going to come to you and the doctors like, whoa, whoa, whoa, whoa. You have a mobile clinic. You're going to the patient. We don't do that. Patients come see me. They wait months to see me. And I'm like, why are you bragging about patients waiting to see you? Like something's unconscionable, but a doctor would brag that you're you have these long wait lists.

Don't stop bragging, stop bragging. It's not good for the patients so. 

[00:50:01] Griffin Jones: That's thinking like an individual contributor as opposed to an entrepreneur though, because the entrepreneur wants to scale the individual contributor wants. Yeah. It's like, oh, sweet. I'm the best. 

[00:50:12] Gina Bartasi: Yeah, well, and again, I think now we have, if you count all of our providers, the APPS, the REI's the OB GYN, there's 65 or 70 of them.

Now, maybe it's 75 or 80, I'm losing, but there's enough now in the industry that they do call, you know, they do call and say, Hey, it'sKindbody hiring. We have in our slack channel, we have a new hire and there's a big referral network through the doctors in the embryologist. So it's gotten significantly easier in the last 12 to 18 months.

And then again, you look at these extraordinary leaders on the clinical side and again, both our scientific lab site, as well as our practicing. 

[00:50:53] Griffin Jones: I know the criticism that I'm going to get after this episode, which is I've been blowing sunshine for Kindbody for the last 15 minutes. And so no, I'm not because one, I can't evaluate you on a clinical level.

I'm not qualified to do that ever. And and even I'm not qualified to evaluate you all on many of the areas of, of your business model. I don't know. I don't know if they're a good or bad what my wheelhouse is brand and creative messaging. And for those of everybody listening knows that that's what I care about most.

And I'm not making this up, you could look at our scale. If you want, you can look at our spectrum. It's empirical kind of body is a four on that. And I think it is a huge advantage that the other networks don't have. Again, oh, you're blowing sunshine. No, I'm not. This is an advantage.

The other networks have a disadvantage of your there IGA. If anybody remembers the IGA soup or like a True Value, they bought hardware stores. Where kind buddy has the Starbucks advantage. I think it's such a disadvantage for these networks that are, that are going for scale to not have any of the advantages of scale that come from brand, which is not window dressing for all of the reasons that we just talked about the instead of it's we're Joe's coffee in Seattle brought to you by we're we're coffee roasters of Denver brought to you by so-and-so over here versus Starbucks where Starbucks, where Starbucks and that there's something about that, that, that pretty lady in green that you invites the customer to be able to recognize something that unites them, to be able to express it themselves, as opposed to just someplace else and the employees that want to and do work for there.

It's like, this is what we're about. And so when did that, when did you know that that was going to be a thing? Like when did you think about doing it the other way at first? Like, oh, well maybe we'll be a network. 

[00:52:50] Gina Bartasi: No, we were always going to establish a brand. We were always going to have these warm colors.

We had three focus groups, three dinners and three focus groups. So six meetings and we would pull the audience. Do you like yellow? Do you like purple? Do you like warm? Do you like hard edges? Do you like blue? Like. And this brand is where it is because we gave the brand to consumers, to future patients, to existing patients and future patients.

And this was before COVID, you know, we had in-person meetings, we sent out surveys. We still survey patients. We want to know, because I think if you, you establish a brand three and a half years ago, you ought to check in on it every four to six months to say, Hey, am I on the right track?

We do. We measure NPS. We are maniacal. We have a 90 NPS, which is unheard of in the healthcare field. It's definitely unheard of in the fertility field, but we measure every single we want to know from patients how we're doing. We want to know that patients have this affinity for the brand. Doctors and nurses and our front desk team to fill an affinity and a protector of this brand.

So, you know, thank you for the accolades and the kudos. If you were able to measure our clinical success rates, like we have a responsibility to report to the CDC and SART you will see that they are above the national average. Now they're above the national average because we're big proponents of GPTA, but they are in line with our peer group.

And I think that was, you know, everybody said, okay, you can build a brand, but maybe your clinical quality would have to sacrifice, oh, well, you know, how are you able to offer an IVF cycle at 25 to 30% less than everybody else? Like you use technology, you know, Dr. Nicole Noyes just joined Kindbody and New York and you and patients are now going to be able to see Dr. Noyes at 30% less than they were paying at Northwell at NYU. Okay. I am ecstatic about that. I am so happy for a patient because many patients that 30% additional charge would have been out of reach, much less patients that have to go through two or three or four cycles. So we continue to be on a mission to provide more accessibility for all a premium experience, without a premium price tag.

[00:55:15] Griffin Jones: I want to say something about somebody that I've been reluctant to say that about two other companies too. And the reason I haven't said this is either in an article or on the show is because I think that people will either think that I'm insulting them or that I'm propagating them. And I'm really not doing either.

I'm really just saying mucho ojo pay attention, like really pay attention to what they're doing. That I don't feel get enough respect and what, so I've made, like I'm saying, I don't feel like they get enough respect. What I mean is pay attention. And that's you all it's Fertility IQ at CNY Fertility. And and so like where you are in this journey.

I don't remember if it was Nelson Mandela or Desmond Tutu, who that says, you know, first they ignore you, then they laugh at you, who then they fight you, then they join it. Where do you feel you are on that trajectory? 

[00:56:05] Gina Bartasi: It's hard to group everybody in the same bucket, because I think, you know, the end, I think some are still fighting.

Some have already joined and then some are still making fun of us. Despite our clinical success rates. Despite we have 84 clients, they're fortune 50 customers. They're big blue chip customers. You know, we have a sign in every single Kindbody location. And as we have lots of art, because we think art goes back to the quality of the brand, but there's a sign that says underestimate me.

That will be fun. And so, listen, we don't mind, like I I've had a lot of criticism throughout my career. You get tougher at it. You get accustomed to the criticism because you're doing something new. So underestimate me. That'll be fun. 

[00:56:59] Griffin Jones: What is on the horizon for you all? What is Kindbody need to accomplish in the next year or, and more interesting like what's going to happen next with the brand?

[00:57:13] Gina Bartasi: You know, again, we've talked a little bit about it, but I think you'll see the brand globally. And I think you're going to see the brand more and anything Griffin, where we let go of the patient, if you prioritize the patient, but then you send the patient out for genetic testing, or you send the patient out for carrier screening, or you send the patient out for donor egg or donor sperm or surrogacy.

When we let go of our patient, that makes us nervous because we are maniacal about patient care. And we're not sure that all of the other people that we're referring the business to are as patient-centered as we are. Yes. We trust them, are they're our partner today, but I do think you'll see us extend the brand to other ancillary businesses where we may be outsourcing.

Now we're going to pull those services in house. You know, I want us to be a leading brand amongst same-sex men, amongst single moms by choice. We've done a really great job. I was going to say same-sex women, but we have a lot of same-sex women, men that trust this brand, but I just want it. I, again, we're, we're so oriented towards this mission to increase accessibility for all.

[00:58:21] Griffin Jones: Why didn't venture come into this before? So when I have David Sable on this show, we talk about private equity. They're buying clinics, it's their model to buy a clinic. Venture capital is looking for something that will scale. So they're normally looking at like AI or software, you know, other, other kinds of tech because they want that scale.

And many of them don't feel like, oh yeah, clinic model is something that we can scale. What how were you able to pitch this to venture to say, oh yeah, this isn't a private equity play. This is actually something that we can scale. 

[00:58:54] Gina Bartasi: You know, it probably goes back to track record.

I think venture capital people are fearful of CapEx, heavy businesses, like standing up for wall clinics, you know, before we hired a single doctor or stood up a clinic, we own our own technology. We invest in it. We have 55 engineers and engineering and it and dev ops. So there is definitely a tech play.

It's one of the reasons our doctors can be more efficient. They can see more cases because we're not doing all the menial work. I know the VC community, you know, and, and so it was significantly easier this time to raise money than it was five years ago or 10 years ago. So, you know, venture investors, all institutional investors, like pattern recognition and they say, oh, you know, gene has been able to do this before genus, you know, this is Kindbody is my third company and women's health.

It's my fifth startup, which just means I'm crazy. But you know, crazy fun. Like , it does get easier. You're able to build teams easier. You're able to raise money easier. You know, Kindbody has challenges like every other business that's growing has challenges. But today, when we see a challenge versus 10 years ago, in many cases, I know the answer, or I know the person who knows the answer versus when you're just younger or you're a newer entrepreneur.

You spend a lot of time evaluating the answer to that question that was just posed today. Questions and problems come up, but I'm like, oh, I've seen this one before. Here's what we should do. You know, and same thing with Dr. Beltsos and Beth Eschbach or Greg or Lynn or any of our team, like you have an incredibly experienced team with a long depth of knowledge and scaling other organizations.

And that's one of the things that's allowed us to execute this quickly in the short amount of time. This well is a Testament to the experience to this team. If Dr. Beltsos and I tried to do this 12 years ago, when we first met at PCRs and she had all these Christian Louboutin on, like, I am in love with this woman, I don't think we would have been as successful 12 years.

It'd be interesting to ask her that, but 12 years ago, we just didn't have that same level of knowledge of experience. 

[01:00:59] Griffin Jones: That's why my client services firm is completely cash growth because this is my learning speed. Yeah, no like it's my learning speed. I will probably do faster things in the future, but I'm really trying to nail the fundamentals right now.

And cash growth has allowed me to do that. So for those that raise so much money and do it so quickly, it's a. 

[01:01:25] Gina Bartasi: Well, I don't know how old you are Griffin, but let's assume that Dr. Beltsos, so are at least a decade older than you. And that's the experience I'm talking about. So does that help. 

[01:01:36] Griffin Jones: Help there's hope for the rest of us?

I will let you conclude, you know, our audience is REI, is its fellows. It's practice owners. There are a lot of PE and venture people that pop into this podcast when they're doing their, all of their due diligence and studying of the field. So how do you want to conclude to that audit?

[01:01:58] Gina Bartasi: Yeah. We've been incredibly blessed and I just want to thank I think the criticism makes us stronger and makes us better. And then those that have been huge, enormous cheerleaders. Thank you. Thank you, Griffin. It's been great for you to come to the industry as well and really elevate marketing.

I was a marketing CEO, a brand CEO, and so it's good to have other cheerleaders that talk about marketing and brand in the field. So thank you. Thank you. We've been blessed and. 

[01:02:25] Griffin Jones: With the field was crying out for a D student to come in and build a client services firm slowly. 

[01:02:32] Gina Bartasi: Love it. Thank you, Griffin.

[01:02:34]Griffin Jones: Thanks for coming on. I appreciate it. Take care. Bye.

133: It’s Not That Complicated…Or is it? with Dr. John Storment and Traci Keen

It is no secret that demand far exceeds supply in the world of fertility treatment, a gap franchises like Mate Fertility seek to close. But REI’s, like Dr. John Storment, argue that the training process employed by organizations like Mate merely imply board certification, and oversimplify years’ worth of education and training. Traci Keen believes that her company is serving the needs of patients with integrity and diligence, providing access to care that would be otherwise unavailable due to the lack of board-certified REIs in existence.

Who is right? Is access to care, even if it is not in line with ASRM guidelines, better than no care at all? Is this the evolution of fertility patient treatment?

Listen to the latest episode of Inside Reproductive Health to learn:

• How impactful the care-access gap is to the evolution of fertility treatment.

• Griffin press on the difference between private equity and venture capital’s place in the industry.

• Dr. Storment discuss how fellowship training in REI is absolutely necessary and OB/GYN physicians cannot be equally trained in mini-programs provided by organizations like Mate.

• Traci Keen argue the criticism of Mate Fertility’s training program, how they provide an evolved model of care, and how they plan to increase accessibility of treatment.

Traci's Information: 

LinkedIn: https://www.linkedin.com/in/traci-keen/

Website: www.matefertility.com

John's Information: 

LinkedIn: https://www.linkedin.com/in/john-storment-b4892b1b8/

---

Transcript

[00:01:40] Griffin Jones: 

About darn time Inside Reproductive Health audience about darn time, all the emails that I've gotten from you over the years, the texts that I've gotten from you over the years, when someone on the show says something you don't like. And then I say, oh, Dr. So-and-so or Mr. Ms. So-and-so would you like to come on and share that point of view and almost always is declined.

Finally, add two people willing to come on. And have it out in a discussion. Traci Keen is the CEO of Mate Fertility. We interviewed one of their co-founders. Gabe Bogner a few months back as you may remember a Dr. John Storment he's been on the show before too. He owns a practice in Louisiana whose lab was owned by Ovation Fertility, and we get into the discussion of access to care versus.

The necessary credentialing  for fertility specialists. I've tried to separate those two issues as best as I can because those two issues intermingle with each other, but they have to be discussed separately. I think my electrician analogy works in that case, but you let me know. Where do you side on this?

What do you think from the arguments that were made? Kudos to both my guests for coming on. And hopefully we can have a lot more discussions like this in the future. But what do you think, where do you fall on each side of the debate?

Ms. Keen Traci welcome to Inside Reproductive Health. Dr. Storment John. Welcome back to Inside Reproductive Health. 

[00:03:11] John Storment: Hello Mr. Jones. Griffin.

[00:03:14] Griffin Jones: So Johnny emailed me when I had released an episode with Mate Fertility. And you had some concerns about the model and what was it that made you want and for, well, first off, before I even go there kudos to both of you for coming on the show, because I have a lot of guests on the show and sometimes people email me and they're like, ah, I don't like that idea.

Or that idea is in sounded good to me. And I said, well, come on the show then. And almost always. No, nevermind. And so kudos to Dr. Storment for actually coming on the show, kudos to Traci for coming on to, to answer any questions. But John, what is it that you wanted to respond to?

[00:03:52] John Storment: Well, I think that the key point is when I see the industry, the private equity and venture capital enter in our industry we have to look sort of with the keen eye to see, is this going to improve the delivery of care or is it going to hurt or potentially worse than care? 

My concern for this is that your, I mean, gaves entire podcast, almost. He talked about how we overcomplicate the fertility space and that it's a whole lot simpler than we make it look. And I spoke with several of my colleagues and my concern is two-fold number one. They say that they're mission is to decrease costs and increase access. And yet the first clinic they put, they put it in a, you know, an area that has a plethora of REI is in the university and also in private practice in Oklahoma City. And then their cost is exactly the same as our costs. And then they say, well, we want to, we want to enter the space and put a bunch of general OB GYN after a short training course.

And it essentially it seems like that our entire specialty is about editorials and transfers and not identifying the reproductive. Medical problems and our specialty. And I think that as a group we have to sort of stand up for not, not for defending our space. That's not it, that's not it at all.

 It's we have to say that what we do is not uncomplicated. What we do is very complicated. And so when this podcast came on, there were a whole host of comments made by the group of that are just not correct. And so that's kind of what made me stand up and say I've since talked to some of my colleagues and there's, there are a lot of people around who agreed with that.

[00:05:46] Griffin Jones: Well, let's start with the first one. Cause there's a couple points in there we can get to the deep, to the cost, but I do. And you know, maybe it's a poor choice of words and I said that to gave us like, well, it is kind of that complicated, but let's go with that point, Traci is that there's a reason or at least assumably, there's a reason that this is a subspecialty and that a board accredited and that people have to do three years of training. So what about this concept of, of this re this it's not over-complicating it really is that complicated. And maybe not just any physician can do it. 

[00:06:23] Traci Keen: Sure. Yeah. I think one of the main things to look at is that the way that our model is actually built, we are very much honoring what REI is bringing to the table.

We have a number of REI that we work with in our tele fertility model. And. We are partnering with OB GYNs because one of the fundamental issues, if you look at few different sides of this problem, we'll call it is access and it's access for all folks, not just you know the folks who typically receive care but in general. And so what we're actually doing is providing the initial lift training to upskill, OB GYNs, to perform retrievals and transfers under the supervision and ongoing quality care and control of a qualified REI, board certified REI. 

[00:07:17] John Storment: Oh, there's board certified RIA is going to be in that clinic supervising them.

[00:07:22] Traci Keen: Well, I guess to that specific question I would love to know sort of in your model, I know that you're not the only staff member and I do believe you have an OB GYN on staff. Are you in the room every time they're performing any type of fertility related service for your patients?

[00:07:38] John Storment: Who is the OB GYN that I have in my model?

[00:07:41] Traci Keen: I believe you had an OB GYN listed on your website. 

[00:07:44] John Storment: If I had two OB GYN, or they were just general GYN as they didn't do any fertility, they did just GYN. One of them has passed away. One of them is retired. So, no, I don't have any, 

[00:07:54] Traci Keen: My larger point would be that there are only two countries in the world that require a fellowship.

Now we're not saying that we don't want to honor that and utilize that.

[00:08:03] Griffin Jones: Well, there's two countries in the United States in Canada. 

[00:08:05] Traci Keen: That's correct. So we're not saying that the information in the fellowship is not valuable. We're actually saying quite the opposite, but what we are saying is let's enable everyone to practice at the top of their license and utilize REI is in a more strategic and efficient way to oversee the part of the care.

As you said, you know, it is very complicated. I think it would be you know, but what we're trying to do is enable REI to provide initial and ongoing upskilling to OB GYNs. However, those OB GYNs are not just practicing Willy nilly on their own. After the initial upskilling there's ongoing quality control and analysis.

On behalf of our team, we have an advisory board, there are monthly meetings to do QA there's daily touchpoints between an REI and during the protocol management process. We have IVF coordinators. We have you know, multiple REI is involved not only in the standard of care review, but also in retroactive review of all things that have happened.

So what we're trying to solve for is really that, you know, 42 REI's are graduating fellowship. I believe on an annual basis, somewhere around that. And when we look at the disparities in the market for the need versus the demand, the demand for care versus the supply, it's simply not there. So rather than focus on, you know, who's right or who's wrong, what we're trying to do is come up with a solution that will meet the need of people who actually need care in.

[00:09:44] Griffin Jones: We do have to focus on it. We do have to focus on that because access to care is an issue. And I do, and I'm going to press Dr. Storment on that, in this conversation, but it's also separated from who's qualified to do it. There's a shortage of electricians.

There's a shortage of plumbers out there. If. We can only assumably lower the licensure, whatever the requirement is to be a master electrician, a journey electrician so much before there's fires and everything. It doesn't, it doesn't change the problem that we need more electricians. And that there's a huge shortage there.

But what about, so, John, what about Traci's point of that level of supervision? What makes that inadequate in your eyes? 

[00:10:26] John Storment: Well, so you over simple, they're oversimplifying it way, way, way too much. And here's why. Patients don't come to my door and say, Hey, I'm a simple infertility patient. We just need IVF.

And, you know, we're going to be easy. We're going to get 15 eggs and we have no other complicating factors. 

[00:10:45] Traci Keen: I don't think that anyone on the Mate team is actually saying, this is going to be easy. We actually take what we're doing quite seriously from patient intake, all the way through it. 

[00:10:55] John Storment: Absolutely, Gabe says that. Gabe said we don't want the complex.

We want the simple, and so let me finish my point. When a patient comes to me she doesn't come to me and say, I'm simple or uncomplex, it takes a thorough history. My three years of fellowship in 25 years of experience, not identifying teaching me. How did those, it didn't take me that long to learn how to do a retrieval and transfer.

I absolutely do not think that a retrieval and transfer takes three years to learn. I am saying that. The complexities and reproductive medicine don't show up easily and it takes years of experience and it takes our fellowship to identify this. Your OB GYN who has a week long training course in Mexico.

And then coming back up to here does not have the training to identify those complexities. I had a patient yesterday this morning. She had, she has had a tubal ligation, and she has four year point number that she just failed to you. A number of transfers amongst the simplest case there. And she has a lot more complex things going on that are not going to be addressed by a general OB GYN, no matter how many touch points you have, simply you're, it's just not able to be taught.

in a week-long course. 

[00:12:17] Traci Keen: It's not a week-long course. It's actually quite a bit more significant than that. And it's not only, I'm sorry. So let me finish what I was saying. It's actually not a week-long course. It's an extensive remote learning and also onsite training. We do not at any point announce now we're not sending people to Mexico.

That was someone that we were working with prior. We've actually restructured quite a bit internally including myself and one of the things that is really important to us. You know, when I look at the fertility industry, I went to college with the first IVF baby ever born in the United States of America.

So when you're looking at me, you're looking at the exact age of this practice in the United States and what we're trying to do in reality, versus I think the picture that you're trying to paint by what you're saying, without understanding the full picture of our education program and our ongoing support and education.

What we're trying to do is acknowledge that this is an ever evolving industry. This is an industry where there needs to be a lot of quality control. So we're trying not only to increase access by upskilling people to participate in tandem with REI. We're not saying go out there on your own OB GYN and practice and just do it on your own.

That's not what we're saying at all in fact.

[00:13:40] Griffin Jones: So go into a little bit more I'm cutting you off Traci, because I want to keep us on this point. Please go into a little bit more detail of the training that you all do because somebody else, a different physician in a completely different part of the country for all I know, doesn't even know John texted me the same thing. What are you doing? Having on somebody that trains their people in Mexico. So please clarify what it is that you all do for your training programs. 

[00:14:03] Traci Keen: Yeah, sure. So we actually, we have an LMS and we have 250 hours of required learning that actually have testing as they go along.

That's in the initial wave and we are constantly creating new materials for that LMS. And then we have a facility that we've partnered with for observations to occur for education. And then when it's time we also have a licensed professional go on. To train in person with them. And we also have our Oklahoma facility where people can also visit as well.

So we're not doing anything outside of the country at this juncture that actually predates my existence with the company. So you know, that's one of the things that is important, you know, we, we take quality of care incredibly seriously. And so does everyone who's involved with this company at this juncture.

You know, I think if you look through our roster currently, we have pretty extensive experience of some very well-respected people in the field who also see the issues in the field and the, you know, typically. And one of the things that Dr. Storment mentioned is, you know, when private equity or venture capital goes into a space, typically we see three things happen.

We see increased access, decreased price, and higher quality of care or standardization of care. Well, we're not typically seeing those things particularly in the fertility market, you know, costs aren't going down, access isn't increasing. In fact, it could arguably be decreasing slightly because we have a wave of REI who are about to retire, which is going to further constrain the already constrained supply.

You know, when you're looking at a population estimates are 30% if you're including LGBTQ genetic disorders in need of fertility care and only 2% receiving, you know, to me, that's a big problem. And instead of focusing on divisive things, you know, why are you doing what you're doing? You know, we are mindful, incredibly mindful of the quality and standards of care.

But I would be remiss if I didn't say we are taking a unique approach because nothing is being done to solve the access or supply shortage here.

[00:16:12] Griffin Jones: Well, I was going to ask Dr. Storment that question, but you know, when you say you're taking a unique approach maybe, and maybe we'll have time to talk about that a little bit later, but I want to say Mate isn't the only group that's using advanced providers or OB GYN to do what REIs sometimes do. And. So John, I want to know what, where's the limit to that. And by the way, that has increased. Since I've been in the field in 2015, there were very few people doing that, you know, maybe Dr. Kiltz, Dr. Magarelli, Dr. Amols a couple of others now it's, there's a lot more people using nurse practitioners for retrievals, if their state allows it or, and, or they're bringing in OB GYN on staff because of this bottleneck. So what's the limiting principle, John, where does. Where does it become something that is not within the purview of the care they can provide?

[00:17:05] John Storment: Well I agree with you. I think that, I mean, I have two PAs on staff and both of them have been trained under supervision to do IUI, HSEs and ultrasounds. And so they, they do them when I'm in the office and if there's problems and we're there to back them up. That's done in almost every aspect of every other type of specialty and how you appropriately use either an OB GYN or nurse practitioner or a PA is probably the crux of what we're talking about.

Right now a PA could come in and do a lot of the things that I'm doing, that they could do a short consult. They could do a lot of the things that I've taught her to do. And I don't think that the patient is getting changed as a matter of fact, because she's able to spend more time with the patient. I think the patients perhaps get better care.

Because of the time that she's able to spend with them. But when, when you're talking about the person in charge of the clinic and the head of the ship is in Oklahoma city is Dr. Patel. So he's greeting the patients. He's seeing the new patients they're going through the things. And then, so does that person who doesn't have REI training and to her point about the United States being unique and that they have a fellowship.

 This has been a fellowship since 1973. And to say that it's can be watered down to a short course and to teach them how to do that. 

[00:18:30] Traci Keen: It can’tbe watered down at all. We're just, there is a bridge here.

[00:18:33] John Storment: Okay, well, let's go back here. 

I'm sorry, real quick. There's no bridge. There's no bridge. When the doc in the office is the only one doing the retreat, the retrieval, what happens when he doesn't have experience in putting when you're three millimeters away from the external iliac.

And it's just not as simple that an OB GYN can go to a short course and learn how to do these, and also have the breadth and depth of understanding of reproductive medicine abnormalities. The you asked about the bottleneck. I think that the bottleneck can absolutely be improved by using OB GYN in the capacity that they can be used by using PAs.

I don't have a problem with that. I think that the problem I see is the patients are being deceived. The patients who go into on your website. There is nowhere near anybody saying that the doctor who you'll be seeing is not a board certified REI, but that's deceiving to the patient for her to think that your doctor has the same training as a doctor down the street, or the doctor in New York City, it simply is not true. 

[00:19:47] Traci Keen: Well, I guess, you know, my curiosity and this, this could be a slippery slope, I guess, because there are a lot of non board certified REI who, you know, should they be able to, you know, Practicing the same way, the board certified. I think what we're really getting at and I find it a little bit counterproductive to say that we're being deceitful.

We actually believe in creating a lot of transparency. We're not trying to deceive our patients at all. What we are trying to do is educate increase access And I know that you mentioned that our pricing isn't actually lower. But we do a what's called bundled pricing.

So for instance, a lot of times. We're bundling everything together. So all the ultrasounds are included, et cetera, which can be, you know, $700 per ultrasound. So we're just not going to nickel and dime people through. So when they use the calculator on our website, they know exactly what they're going to be paying for the entire service and there are no surprises. So, you know, I won't say that more affordable than every provider out there, but we do try to keep costs in mind and we do try to build in solutions to make this more accessible to more people. And that's really the crux of what we're trying to do. You know, we're actually trying to honor the REI fellowship by ensuring through our model in a way that.

There is a high level quality of care being delivered. There's ongoing education. There are daily touch points. There are highly trained IVF coordinators paired with every clinic. There is a day to day protocol management oversight by the REI. So, you know, for all intents and purposes, I think that we're trying to increase not only access, but also we're trying to standardize and make sure that there's accountability and oversight along the way. And I guess one of my thoughts is, you know, If you think about, if you were to tell people 15 years ago that you would order a car on your phone and then get into a vehicle with a stranger people would've looked at you like you were crazy and now people do it multiple times a day, every day, Uber, I take very seriously the integrity of our programming.

That's why we've actually, you know, very proactively gone out and found people that we find to have incredible reputations in the industry who also believe in what we're doing, because it comes down to responsibility, access, affordability, standardization of care. And we do feel like we can deliver those things via our model.

[00:22:24] Griffin Jones: So I want to zoom into the Uber point for a second, because that ties into a point that I wanted to bring back to John about. The onus of that transparency. So part of the reason why Uber was able to replace taxi cabs at that scale is because both the public and finally, the governing bodies decided that a taxi medallion was not requisite licensure for carrying a passenger safely to another place.

And John, so when you put that onus on them and saying that, you know, Mate's copy on their website is deceptive. I'm not convinced of that because I don't know who the owner is. If I hire an electrician, is it the electrician's job to say we're a journeyman electrician versus. Sure electrician. It's the view of the governing body that says, this is what a journeyman electrician is allowed and able to do.

This is what a master electrician is able to do. So what's in violation with what governing body here? 

[00:23:17] John Storment: I said, it's a great question. And it goes to broader things of some way. Traci said earlier, You have a lot of people practicing outside of their specialty and medicine, all you need is an MD behind your name to be able to prescribe.

I don't even have to do a residency in order to prescribe medication. So there, it's not a great system to sort of prove you say, oh, he's a doctor. I mean,, here's an OB GYN in our area who is doing plastic surgery. They're doing breast augmentations and me. And I have friends who have gone to them and I'm like, you know, why are you going there when they're board certified plastic surgeons?

And the answer is, well, I just thought that since they hung a shingle up, that they were, we're assuming board certification. And so you're 100%, right. That there's not a standard to say. You can't practice without board certification. Board certification does indicate that you've reached a higher level of training and high level of your testing.

And some people are grandfathered into that and some people are not. And so there are people who are not board certified who were practicing and they might not become board certified because of their research project or because of some things that are tied to that. But the realm of being board certified does offer the patient information that they did their training.

They took the written exam, they took the oral exam and they passed all the points. The American board of OB GYN say that's important. And so it is unfair to the public for that person to have the same, the impression that plastic surgeon. Who's really an OB GYN is the same as a plastic surgeon who did a plastic surgery fellowship, but this is much the same.

 If it were be honest, he would say, look, I've got Mate Fertility, we've got four births are board certified already. On our advisory board, but the person you'll be seeing day to day is a general OB GYN. And if you say that and the patient says, I still want to go to this guy, he's really a nice guy.

He's a good doc. Then go to him just like you can go to the OB GYN for plastic surgery. I mean, but you have to be transparent and that's.

[00:25:33] Traci Keen: I think that we're being quite transparent about what we're doing publicly and You know, we're not hiding anything from anyone. In fact, we're sitting here talking about it right now on, on a podcast that lots of people will listen to, you know, one of the.

[00:25:47] John Storment: The general public can listen Traci. 

[00:25:49] Traci Keen: Please let me finish. You know, one of the things that I think is really important to acknowledge that. You know, we're inviting in the REI community. We are trying to embrace on an ongoing and very active basis. The ASRM guidelines we're trying to make sure.

And I think we're doing a pretty good job of it. ASRM itself has issued statements about OB GYNs performing fertility services and. You know, we really do believe in the integrity that you're speaking about. That's why we're inviting the REI community. And we're actually not trying to take a piece of anyone's pie.

We're saying let's bake a bigger pie and let's do it together. We're taking a collaborative approach. So solve the true problem, which is access the, and who loses in the end from not having access to care is the patient. You know, so if this, wait, if this is just truly about the patients, what are we going to do in the fertility industry Dr. Storment? And I'm asking this to you, how would you try to solve the issue of creating more providers that can. In good faith perform these services. And I'm genuinely curious because I feel like we're taking a problem solving approach to a big problem in this country, the world health organization in 2017, declared it a fundamental rights to build a family.

And, you know, we not only have issues with LGBTQ individuals receiving care. There's geographical issues. There are financial issues. And when only 2% of the population is receiving care insurance companies, aren't incentivized to mandate care because so few people are receiving it

[00:27:33] John Storment: So, I'll go to your first question about access to care.

And I think that that's I've thought a lot about this. I've had some discussions with some of the program directors and the problem with only graduating 34, 40 fellows a year is that's clearly the problem. We all agree to that. And I think that the take is that most fellowships, or at least a lot of the larger fellowships have the opportunity to train more than what they're training. One program director said that she's she's puts out, you know, one graduate a year. She has a total of three fellows. She said I had the capacity to have four times that amount, but I don't have the funding for that. So instead of private equity or VC partnering with general OB GYN to, to increase what might be considered a less trained individuals.

Why don't they put their money into partnering with programs, fellowship programs, endow these fellowships with more money so that they can graduate more people. I would love to see more well-trained board certified REI guys out there that come from well-established programs. And it's not easy.

I'm not saying that it's easy, but I think the money when they partner with private equity and VC partners, Our academic institutions and to create more fellowships that are training better people, that's where we're going to get if we went from 40 to 60. And I think you said in a podcast earlier, but I Griffin you said, you know, how do we get to a hundred graduates a year?

And would that solve our problem? And the answer is probably yeah, because it's going to take a long time to do that but. 

[00:29:12] Griffin Jones: How long are we gonna wait? Because people have been saying this since Dr. Kiltz started his model however many years ago. And everybody is saying we need more fellows.

We need, like, how long are we gonna wait for this versus before Mate comes in before I let you respond, Traci, I want to, I was surprised to hear you, Traci use private equity and venture capital in the same sentence, doctors do it all the time. But if I were you, I wouldn't because those are two different camps there.

I wouldn't that I don't necessarily want to get in bed with the other. And it's important for people listening. So I'm going to make a distinction because there's a Venn diagram of the two overlap, private equity for the people listening generally coming and purchasing existence. Existing businesses on a multiple EBITDA, increasing profit increasing efficiencies so that they can then sell it up multiple for an exit within a couple of years, usually taking a controlling stake venture capital on the other hand, coming in much earlier stage businesses.

Some that even have haven't even proved a concept yet providing seed funding, letting them get started, usually not taking a controlling stake and. With the idea that they end up scaling into a much larger business. So that would explain why some models would do something and some would others, but all the time, I'm always hearing doctors say venture capital, private equity, very different things.

Know the difference. If you want to see where they come together, watch Shark Tank, because you can act because it's typically a venture play, but sometimes they'll make a private equity play. And so you can actually see where those rings of the Venn diagram. Come come together. And so, oh, I guess like talk a little bit about this, Traci why not the incentive of saying, okay, let's be the ones to make sure that these fellowship programs get off the ground and then funnel that into a different system? 

[00:30:58] Traci Keen: Well, you know, I don't know why, you know why not? I think that if that's really, you know, something that Dr. Storment's passionate about, I think he should start pushing for it and create, create that business. Right. You know, it's not our particular model. I think we're taking sort of more of the approach that is taken in other areas and things like where it's almost, you know, we're learning by doing we're teaching by doing.

You know, again, we really are trying to solve for a couple of different things. And one of the things that's important to acknowledge is even if we increase the number of fellows graduating from these programs, generally speaking, they're not going to and we see from the. You know, I think the latest CDC report, if you look at a map of where there's actually fertility care available, there are high concentrations in very specific parts of the country.

And then there are what we call fertility deserts throughout the United States. We look for fertility deserts because just because there's no care, there doesn't mean that no. 

[00:31:58] Griffin Jones: But OKC wasn't a fertility desert. 

[00:32:00] John Storment: Absolutely not, OKC wasyour first clinic. So why don't you go there? 

[00:32:05] Traci Keen: Well, one of the things is if you look at the population density there versus the available care, it's not enough to serve the entire market.

[00:32:14] John Storment: You could've gone to a spot that didn't have anybody. Well, when you have gone to a place that they have two busy clinics and there's a month wait list to get to see any of them right now. 

[00:32:23] Traci Keen: Well, you said one of the key words, you know, when we look at markets, if we're seeing long waits. We realized that there's more need than is being provided in that particular geography.

And so we would like to alleviate that, I think as a REI, I think as an REI, you would know that time is of the essence. When you know, when somebody realized. 

[00:32:45] John Storment: But Traci, if you have, right now. 

[00:32:48] Traci Keen: Storment I would really beg beg of you to sort of you know, the solution of pouring more money into institutions to create more training. I think that that should absolutely happen, but I think there's nothing wrong with trying to solve it the way that we are. I think that we are doing it in line with the guidelines and the the fertility providers. Yeah. I think to say that we're doing something out of compliance with ASRM guidelines would be not accurate.

I think that.

[00:33:18] John Storment: I 100% disagree with that.

[00:33:21] Griffin Jones: Well, let's zoom in. All right. So then John, where are they not in line? Where's Mate Fertility not in line with the ASRM 

[00:33:28] John Storment: real quick, I'll get to that, but let's go back. She didn't address the fact that there was a month and a half long. Wait right now, that's not that long for you to see.

So the doctors are either one of the practice. There are a ton of places that don't have REI at all. So why go to.

[00:33:46] Traci Keen: You're trying to go into all of the places that need us. We have to find the right partners in each of those markets. And once we do, we plan to go there, you know, we actually look at the markets a lot differently.

You know, there are certain markets in the United States. Do we want to open them for a Mate, Fertility and LA no, it's saturated. Do we want to open one in New York city? No, we don't. Do we want to open one in Massachusetts? No, they have mandated care. Therefore they're receiving, you know, highest rates in the country 5.5%. 

[00:34:18] John Storment: And you guys take an insurance. Are you all insurance plans? Are, y'all not going to take insurance?

[00:34:22] Traci Keen: Currently. We don't, we will provide superbill so that people can submit that to their insurance. And we are trying to facilitate as many points as we can.

As an early stage business, we will evolve. 

[00:34:37] John Storment: Well, it seems interesting that you're trying to increase access to care, but you only want it with the cash pay patients 

[00:34:41] Traci Keen: what we are trying to create a model that can be replicated.

[00:34:46] John Storment: Why don't you use our model? Why don't you take insurance even on the low paying patients so that you can increase access to the people who have lower paying insurance? 

[00:34:57] Traci Keen: I think you, did, end of what I said is that we will, if someone has coverage, we'll provide a superbill for that and the. 

[00:35:04] John Storment: That is not, absolutely not covered.

Progeny is not going to allow you to be on there because you're not board certified already out there. There are a host of. 

[00:35:16] Griffin Jones: Well, why not Traci? Because it's hard to make an access to care argument. If you're not taking insurance, 

[00:35:21] Traci Keen: You know, right now it's just not in our model. We do plan to extend and expand our model.

[00:35:27] John Storment: I love not to take insurance either, because I would love to, to be able to charge you what I want to charge you. The reason why some clinics. You know, $2,000 more than you're charging is because they're not because they're also taking the, you know, Aetna and United healthcare that are paying them $4,000 less than you're charging.

So that's the reason why. 

[00:35:48] Traci Keen: We do intend to constantly evolve our model continually, but as an early stage business, Dr. Storment where we're trying to solve for the access issue. And I agree there are problems, you know, but I think. 

[00:36:00] John Storment: You are not solving access if you only taking cash pay patients. 

[00:36:03] Traci Keen: I think that what would actually be a more curious question again? And I'm trying to look at this macroscopically, not microscopically, you know, I think that attacking people who are trying to create more access, you know, we can go all day about it, but.

[00:36:20] Griffin Jones: I think, and he's making the point that you're not expanding access.

So it's not that he's, Dr. Storment argument is sound then he's not attacking expanding access, he's questioning why you're not expanding access with insurance. 

[00:36:34] Traci Keen: Yeah. So what I would say though, is that you know, mandated care would actually expand access more quickly and sometimes things happen in reverse order.

So our thought process is if we increase the number of providers, thus we're increasing the number of treatments. I think that we're more likely to be able to garner the interest for mandated coverage when there's more access, sometimes things work in reverse. Mental health care wasn't mandated coverage until it became more widely acknowledged and accessible.

So we're taking a reverse approach. It may or may not be what everyone agrees is the right approach, but that's the approach that we're taking right now. It doesn't mean that we're not going to continue to evolve our model and eventually potentially take insurance. It's just not something that we're, we're biting off at this time.

[00:37:24] Griffin Jones: Let me remark with regard to the same, I've tabled the, the topic of the ASRM guidelines, because I do want to come back to that, but what you're hitting on Traci is that there's a natural tension between entrepreneurial venture- period, no matter how it's financed-and the practice of medicine. Dr. Francisco Arredondo is going to come back on with his book “MedikalPreneur”. some things I agree with him on some things I don't. I look forward to having him back on, but there is a tension, no matter what people like to say between, and I'm not saying it can't be reconciled ever, but there is a tension between entrepreneurial venture and the practice of medicine in that entrepreneurship prove a concept, fail early reiterate, then build systems to deliver at scale.

And a lot of physicians and clinicians have a problem with that because the practice of medicine is not about that. It's about credentialing, it's about experiment and proven experiment and randomized controlled trials. It's very different. And so, you know, the changing of your model and the changing of many other business models.

It's not this Mate isn't singled out here, but of all of the groups whose model is changing, it's like, you're not the same CEO as the founding CEO. Why not? You have this model for building into OB GYN clinic labs, but you've got to a brick and mortar and OKC. So like, don't you see what the concern is here with with entrepreneurs coming in and having a changing model?

[00:38:44] Traci Keen: Sure. I see what you're saying. But I would say that the only constant in life has changed, and I'm not saying that to be dismissive of the argument, but you know, we can tackle one thing at a time in more successful and add more layers. Do we intend to take insurance eventually? Sure. Do we intend to create access sure.

These are both big goals. You know, when you're looking at a business that's trying to grow and expand and increase access and you're fighting an industry the insurance industry at large, you know, I think the bigger question is why aren't insurance companies covering fertility care. You know, wouldn't that actually facilitate funding of more programming.

There are other things that could happen that would facilitate lots of areas, but we have to be strategic and mindful about how we tackle, when we tackle, what we tackle and, you know, in order to be successful, we can't bite off more than we can chew. If we were to take on 12 things at once and try to solve everything all at once, we would probably fail.

What we're doing is we're taking a relatively linear approach right now that will continually evolve because the nature of a successful businesses typically evolution, you know, I think that what we're trying to do is actually, again, it's a lofty goal, but I don't see it. There are other people I'm sure trying to solve on a smaller scale, but we're really trying to put ourselves out there and again, I would be remiss if I didn't say we're inviting in the REI community, Dr. Storment, you know, if you have ideas as to how we could make this even better, what we're doing, I would welcome your opinion on that and participation, because I think that it's important to look at it holistically and say, who loses in the end?

If we don't start to expand this access. And we can argue all day and night about whether we take insurance or not. And again, I hear the argument, I don't disagree with it. But what I would say is, again, we have to take things one at a time as a business. If we're going to be intelligent about how we approach the problem in the first place.

And I think, you know, we've chosen to go about it the way we are for now, and we will continue to evolve. But again, I would welcome more constructive input as opposed to destructive, because I think destructive really doesn't produce any positive results for this industry at large, 

[00:41:07] John Storment: I wouldn't be in destructive and I will tell you that as we discuss this, we keep flossing over the most important part of this.

And that is that you're putting out a non fellowship trained person doing a job. Many would argue, needs to be done at least directly supervised by a fellowship training person. And so it's not the Uber argument. Doesn't hold water because the guys who were driving the cabs don't have three years more training than the Uber drivers were coming in.

I take Uber. I love Uber. I think it's a great concept because what they did is they found a need that the cab drivers weren't doing a good job. And so he said, let's try this, but there's a where it doesn't hold water is you. Can't just say, we want to do what you're doing. We want to take the cash pay patients.

We want to take the simple wins. We'll leave you the really complex ones. And then we're going to just take our money and take those patients. 

[00:42:09] Griffin Jones: But cab drivers made the same argument, John, so let's go back to the ASRM guidelines. And so where is Mate Fertility far from the ASRM guidelines in your view?

[00:42:20] John Storment: So there's a ton of ASRM guidelines and you're right. They have, they have made, they have had to make guidelines as to how you incorporate a PA. An NP. And also what's the role of the general OB GYN. They're not about to go out and say something that you can't use general OB GYN in your clinic because of the, of the problem of access.

So they're not going to come out and say, this is illegal, or this is against our guidelines, but they do say that you have to be. Fellowship trained in order to be board certified and the board certification and the fellowship has a whole list of things that we're learning throughout the fellowship.

And these fellowships are not just producing IVF docs. And so I think where they fall short is they're not recognizing the complexity. Of the infertility patient. They're not recognizing that when a patient comes in and she has untreated insulin resistance and she's with the general OB GYN, she might have not have it identified.

She has an egg retrieval. She has suboptimal care and she doesn't get pregnant. Whereas if that person had more specialty training, they would have recognized. That she's a lien PCO that she needs Metformin that she has these other things that go along with her simple complaint of infertility, the patient doesn't know that she has that, but it takes a board certified REI to sort of put together the entire complex endocrine package that she's not, she's not coming with that on her forehead. It's takes a diagnostician and years of experience and a fellowship to identify that I'm not overstating the importance of me because we're great and glorious. I don't, I'm not patting myself on the back.

I'm just simply saying the OB GYN. I don't see a Mate Fertility entering the oncology space to say because there are not enough GYN oncologist, but to try to put a general OB GYN and an oncology space and had to do difficult oncologysurgery or an MFM. That's not happening because it's because that's physically complex surgery and physically complex other things in maternal fetal.

So they're not entering that for a reason they're entering this space because it's low-hanging fruit. And so I think that that's where they, the answer sets up these guidelines, but more importantly, these fellowships for a reason. And it's not just about we want to exclude other people it's it's simply because it takes three years to learn the complexities of reproductive medicine.

[00:44:52] Traci Keen: Well, I would love to ask a couple of questions and, you know, again, I, I approach life and everything with the genuine curiosity. And I do feel like integrity as well. You know, What percentage of the fellowship is academic and what percentage is actual clinical training. And then how much have you had to sort of learn as you go, Dr. Storment and where did you learn that? And how did you learn that as you started your practice, et cetera. 

[00:45:22] John Storment: Great question. The structure of the fellowship is for in general, two years of clinical medicine and one year of productive research. And you could argue all day long and I would have left argued to skip the research here because it's just a wasted year.

And I learned after doing a year of research that I learned how to read and write literature. I learned how to interpret the literature so that I can critically look at it and not just look at the conclusion of a study to help better my patients. I didn't like it going through it, but that extra year of research absolutely made me a better doctor.

And when I got out you're 100%, right. I didn't have all the answers. I was absolutely green. And I started with a group with other docs and they absolutely did helped me to go along. And when I got into trouble, they were mentors, but they were in my practice and they were right next door with me. And so doing a practice on your own is tough and being, and not having backup.

So I'm thrilled that you have supervisory roles and people who are board certified. But my fear is that you've had, you have four REI's and one clinic in OKC. When you expand to 10 clinics. I mean, it's going to make it much more difficult to have this daily touch point access to have appropriate backup.

And that's my biggest fear is that patients are not understanding that the doctor is not fellowship trained and they're just assuming their doctor is the same as the one down the street. And when you have decrease the amount of supervision because of how much expansion you're going to make. Then that creates, in my opinion, a difficult.

[00:47:04] Griffin Jones: We only have a couple minutes left.

And there's a question that I want to ask each of you. I have a different question for each of you that I want both of you to answer before. And then I will give each of you the opportunity to close. So For you, Traci is that you do have REIs on the payroll at mate. You know, that the criticism coming from some REI's is that it is business making decisions that clinicians need to make.

Why did you, the CEO, the business person come on and not send one of your REI? 

[00:47:33] Traci Keen: I'd be happy to someone in the REI and you know, I'll be happy to facilitate an introduction. You know, I think that one of the things that's important is, you know, while I'm not a clinician, I do value the clinician. And we have a, the way that our model is structured, you know, we try to keep church and state separate for the integrity of the business.

You know, business decisions can't be made by clinicians and vice versa. Because that would sort of make the business fundamentally lacking in the integrity around the choices and the decisions that are made. And I came on the show because, you know, I think it's important that we sort of invite people in, because I think that one of the things that I, I believe in as the leader of this company is if there are naysayers out there about.

Tell me, let help us fix it because the access issue is really what we would like to solve for rather than sort of who's right. Or who's wrong about how it's done. You know, we sort of see our programming as a good solution to increase access. You know, three years ago, I think a lot of people. Less keen on telemedicine in general, you know, and now we've all seen by having to be remote for big chunks of our life.

At this juncture that we can accommodate some efficiencies that way we can facilitate more access unilaterally. And that's what we're really trying to do here is build bridges and increase access. And again, I, I welcome anything that can. You know, I've learned a lot from this conversation and I'm going to take it back and continue to build programming that I think makes sense.

We obviously care very dearly about patients and success and the integrity of the programming and want to continue to build it out to be even better to think that we won't change and get better as we go would be foolish. 

[00:49:28] Griffin Jones: Well, John, I want to, and you might want to respond to that, John. And if you do, you can use it for your clothes, but I want to ask you What is the cost of so many areas not having competition?

What does that do to the standard of care? And you're an exception in my view, being in a small market and in some of the markets that you're in, you don't have competition and you have invested a lot in your team building. And what I've constantly said on the show that what used to be business pluses evolves into the standard of care. You know, even referring to mental health providers may have been a plus some years back or having a patient portal. And now online modules like engaged MD or organic conceptions. And, and so like things that used to be maybe like a business or a marketing plus is now part of the standard of care and some of the people that I see in innovating the least in this field are small practices in small markets. And this is not a categorical statement. I want everybody to know, listen it because there are exceptions, but I really see some people that have no fire up under their ass, John. And what does that do?

Because they have this funnel of, you know, 40 plus doctors coming in and none of them in their area. So they have whatever's there. What does that do to the standard of care? 

[00:50:46] John Storment: That's a great question. And I'll go back looking at what Traci said earlier, that it is important to want to change.

Being stagnant is not good. I used to practice with a guy who didn't change his protocols no matter what he did the same dose every time. And he didn't do anything different all day long. That's where he did. He did not have a fire under his ass. He didn't care about advertising. He had an ugly office.

There was nothing progressive about his practice and the patients recognize that that's kind of his attention to that. And it reflected poorly. They didn't feel special. And so showing them that you care, making sure that you change and you listen. And sometimes you're right.

Sometimes a Mate Fertility or somebody else moving into your city will cause you to change. And rather than be complacent, complacency is not good for patient care. It's not going to increase access and you can't just keep going along. And we have to have a fire under our ass and our specialty to recognize that access to care is a huge problem.

And as long as we can continue to not do anything about it and not have increased fellowships and fellowship training people. This is not going to be the only model male fertility will be duplicated and triplicated and people are going to be coming in. They're not going to be the only ones doing it.

So we have to be proactive and prideful of what we've created and not be stagnant. And so to that end, that might be an impetus for change. My contention is change and providing a lesser care. And I'm not saying may fertility providing lesser care. I'm just saying you can change. And it can make things worse than what it is now.

And that's why I'm on this program today, because I don't want the care that these people are receiving to be suboptimal.

[00:52:40] Griffin Jones: Anything else that you want to close out your points and then we'll turn it over to Traci to close out her points. 

[00:52:45] John Storment: I mean, I love my job and I think the best job. I love my specialty and I'm not this old guy saying I hate change.

I love change. I love that we're embracing the LGBTQ plus community. I mean, probably 15% of my patients, or I remember that and I'm in south Louisiana, so that's fairly progressive. I love change, but I am, and I'm not inherently opposed to private equity or venture capital. Being inherently involved in healthcare and I'm not using them synonymously.

I'm just, I'm not inherently opposed to that. But I think the way to do that is to partnering private equity with academic trainings facilities, and to increase the number of trained RBI's. And I just don't think it's a simple story of Uber and VRBO and healthcare. I think that we're providing care differently than what she's proposing.

And I don't think it will be evident for years. After many couples were realized they were being given treatment by doctors who were not trained as ones down the street. 

[00:53:46] Griffin Jones: How'd you like to close out Traci? 

[00:53:48] Traci Keen: Sure. I mean, first I'd like to thank Dr. Storment,. You know, I, again, I, I learned something from everyone that I speak with.

And the other thing is, you know, in your last mentioned, you talked about that doctor who hadn't changed his protocol, didn't change it, no matter what the patient is, you know, we view our collaborative model as getting the best and brightest in a room to collaborate on ever evolving industry.

And we invite in anyone who would like to participate and collaborate with us because we feel like there's something to be learned. And if we're all trying to solve for the same thing there's enough room for every. And you know, I don't disagree with anything that Dr. Storment, instead of course, I think that they should be graduating more fellows if they did that originally when the access gap started to widen, mate, fertility probably wouldn't exist.

But we do, you know, feel very passionate about what we're doing. And I know that there are a number of REI is in the field who also feel passionate about increasing that access and solving for it in innovative ways. And so we're trying to do that. While embodying the highest standards of care and also creating a quality control and analysis system so that we're not delivering the same protocol for 30 years that we're evolving with the industry, which again, it's only as old as I am.

So it's going to continue to evolve as everything does. 

[00:55:11] Griffin Jones: I would like thank both of you for coming on the show for everybody listening, that's ever listened to an inside reproductive health and a guest of mine says something. And you think that damn comment, come on the show. It's obviously a good forum for discussion Traci Keen, CEO of Mate Fertility, Dr. John Storment and REI managing partner fertility answers in Louisiana. Thank you both very much for coming on the show. 

[00:55:35] Traci Keen: Thank you Griffin. 

[00:55:36] John Storment: Thanks guys. Thank you, Traci. 

[00:55:37] Traci Keen: Bye-bye.

132: Why Society is Really Waiting to Have Children with Dr. Duana Welch

This week on Inside Reproductive Health, Griffin Jones and Dr. Duana Welch, author of Love Factually, explore why couples are waiting longer and longer to have children. Science is indicating that the changing landscape and evolution of communication could be the leading cause of later-in-life marriages, as well as couples ultimately waiting longer to become parents. Listen to the full episode to step into the mind of some of your patients today.

In this episode you’ll hear: 

• Why couples are waiting longer than ever to partner and reproduce.

• Men and women have short term mating strategies that are exploited by "swipe to date" platforms.

• Duana talk about the psychology behind human reproduction.

• Duana talk about the evolutionary science behind the 'double standard'.

• How Duana's book, Love Factually, and coaching services, provide a framework to navigate dating today.

Duana’s Information: 

Free content and contacting Duana: http://lovefactually.co

Facebook: https://www.facebook.com/LoveFactuallyAuthor

Twitter: https://twitter.com/duanawelch

Insta: https://www.instagram.com/lovefactuallybooks/

---

Transcript

[00:00:55] Griffin Jones: Today's guest is a little bit of a curve ball for the reproductive health business topics that we normally cover on the show. I've got Dr. Duana Welch with me, Dr. Duana Welch is a PhD psychologist who studies mating and dating behavior. She has a book called Love Factually. She first wrote it in 2015.

She's revised and updated it for our 2022 and beyond world, she has a website called lovefactually.co. She's been a professor at universities in Florida, California, Texas. She's been on PBS and PR Psychology Today. And the reason I wanted to bring her on to our show is because I think that it's an interesting way of exploring why some of your patients are coming to you for the needs that they have for fertility.

A little bit later on in life, we often just kind of chalk it off to career and that's one of the reasons, but you should know what it's fricking like out there, man, for people trying to partner or not. And so that's why I brought Dr. Welch Duana because I think it's a useful way to be able to.

Know, why your patients, some of them are, are coming to you at this age and why they didn't partner earlier on in life and come a decade earlier, or even a couple of years earlier. And in some cases it's just useful for knowing what's happening. So I hope you really find this interview with Dr. Duana Welch to be entertaining.

Enjoy.

Dr. Welch, Duana welcome to Inside Reproductive Health. 

[00:02:33] Dr. Duana Welch: Thank you so much, Griffin. It's great to be here. 

[00:02:36] Griffin Jones: I look forward to introducing you to the audience because and, and by the time I will have done the synopsis tour, I gave the angle for the folks. I think what you study is very relevant to parts of the reasons why many of these folks, patients are coming to them later in life.

And so there are different ways that will come into this angle throughout our convo. Today, I want to start with the book that you had written in the past that you've updated. I believe you've updated more than once. You've updated, reasonably called love factually. And so can you give us an intro to the book and then what had to be updated most recently. 

[00:03:20] Dr. Duana Welch: Sure thanks so much. Well, here's the cover, as you can see it's and this is my first revision. So the first version of this book Love Factually 10 proven steps for my wish to, I do released in January of 2015. So here's seven years later as of February 20 22, we've got a fully revised and updated version.

And the reason is that everything I write is based on science rather than opinion, it's very conversational. So it's not a science tome. It's an advice book. It's a self-improvement book, self-help book, but it's based on science fully referenced in the back. So science did not stop furthering itself just because I finished a book, it went right on.

And so I found that when I was rereading the book about a year ago that I kept thinking, oh, I wish I'd said this differently. Or there are so many studies on this now that I know more about this concept now. So some of the things that we know a lot more about now than we did, then are things like.

How men and women think about the human mating ritual, which is what I call it. Most people in the street call it game playing or something we know a lot more about now is that human nature really hasn't changed all that much, but dating has changed a lot. And a lot of that is because of the ways we're using technology differently than how we did before.

So those are two of the big areas. And other thing is pandemic. This won't be our last pandemic and you can leverage pandemics to actually have better dating outcomes as opposed to worse, which I definitely did in my own life. So I thought I would put that, that in there as well, again, with a scientific basis.

[00:04:57] Griffin Jones: Well, let's start with the meeting rituals that, that men and women have and what needed to be updated about. Your book that you either didn't think about in that way, seven years ago, or you, you came across new literature. What, what was it with the mating rituals that you updated? 

[00:05:18] Dr. Duana Welch: Yeah, so nothing about the basic heart, the basis software that we all come into the world with, none of that has really changed all that much.

Although interestingly, recent studies show that human evolution has begun accelerating about a hundred thousand years ago. It's been getting faster and faster and faster. So the idea that we just finished up a hundred thousand years ago, and nothing has really changed since then, that's not true, but we do have substantively the same mating psychology.

We had 45,000 years ago. The new issue comes about when we put ourselves in new contexts, our mating psychology is the same, but when it's thrown into a new context, one of the aspects of our meeting psychology is that it is very adaptable based on the context. So if you put people in an environment where it seems like there are thousands or even millions of potential mates, they behave much differently than if they're in an environment where they believe they're only one or two.

And for example, they'll treat prospective partners as much more disposable. Obviously, if they think that there are many, many, many potential mates and men and women alike do this, and that's a newer thing and it wasn't even always true that the internet created that idea really. That really got the ball rolling with swiping apps where you don't get much information other than what somebody looks like, maybe a few words you don't, you don't get to any of the deeper information that we know for sure.

Creates lasting, harmonious, happy marriages. You just get something surface. And when people are only given a finite amount of information, they make decisions based on that and not the information they don't have. Right. That's just logic. So if what you give people is here's how I look. That's how they make decisions.

And in the past, men made a lot of their decisions based on physical appeal, no matter what environment they were in, but women usually didn't unless they were looking for a hookup now because of swiping apps, men and women alike are doing that. So it's really kind of messed with our mating ritual and it's creating some outcomes that.

Maybe aren't making people so happy in the long-term they're working out maybe better in the short term. 

[00:07:27] Griffin Jones: So I want to ask, I have a hypothesis that I want to run by you about women looking for appearances more than they had in meeting selection. I have a hypothesis, so I want to run it by you.

At some point, I made a little note so that I did, but I really want. Dig in to this part of the multitude of potential partners that people have to look for them, what that does to the overall courtship process or the partner selection process better said, I know you have a definition for, for courtship, but let me say partner selection process.

Because for those of you listening, if you haven't been single, since let's call it 2012, 2013, you have no idea what it's like out there. You have, it is a different world. I'm telling you it's a different world and I've been on both sides of it. I've been partnered in both sides and, and, and single on, on both sides of that era.

And I can say that it's different, but I think it's so important for the providers listening to know that this is part of the reason why people are calling. Into to fertility clinics later in life. But I said, why they're choosing to have children later in life among other reasons, but people aren't finding their mate at an average of their early twenties anymore or where their teens and what can you tell us about how these rituals have changed in the, like how long it takes for people to partner?

How else has it changed the partner selection process? 

[00:09:01] Dr. Duana Welch: It's really interesting technology, has it shaping us, we're shaping it and it is shaping us. It is we're interacting. Our ancient brains are interacting with these new ways of doing things. And in many ways, they're hijacking.

Parts of our reward system in our brain. So for example, men have always loved to look at young, beautiful fertile women and online pornography makes it where that they can look at that all day, every day, if they want to. Whereas in ancient Japan, maybe they would encounter one or two women that looked like that ever.

And they probably wouldn't have encountered us, strength, no strings attached access because women have fathers and brothers and mothers, and you would have been in a group where kin would have exerted certain pressures on you. And so when you couple that, which of course porn's been around since long before 2011, but the, the advent of like porn.

And free porn. So anybody anytime can get lots and lots of access and anybody's anytime you usually choose to are men, women don't choose to do this so often because we value something else. When you pair that with swiping apps, what you get is the part of male psychology that is attuned to youth and beauty focuses so exclusively on that, that it takes men a while to realize that they're tired of a diet of candy, that they really want the full meal.

And another thing that happens is men really need dopamine in order to fall in love. And what happens when men get instantaneous sexual access is their dopamine levels. Don't seem to rise enough for them to fall in love. So a lot of things that work for getting people to fall in love and stay in love.

A lot of those things, aren't really a big part of modern day meeting. Most women are going to have sex with the guy on date one, two or three. Unless they're very conservatively religious and most men expect that now, and women are afraid not to give it. I was talking to a woman recently who said I don't really want to have sex then because it's basically sex with a stranger.

And I don't really like it, but I feel like if I don't have sex, then that the guy's going to find somebody who does, and this is happening across the spectrum of ages. And what happens is it makes it difficult for people to, especially men to realize that they want. Love and commitment. And then to do the things that would lead to that.

For example, looking at character and not just appearance or looking at values and not just whether you enjoy doing the same things, and I'm not just looking for somebody who looks great and address, but somebody who looks wonderful in her, PJ's at 10 at night when you just want to watch Bridgeton and then go to bed.

And so, things have they're different than they used to be. And when men have this perception that the world is full of tens and they can get one anytime they want. And that there's no end to the supply of potential mates, it's difficult for them to see their way back to the mating psychology.

That really results in deep connection. So you can pull a finding that later. 

[00:12:09] Griffin Jones: And you talked about youth and beauty being one of the things that they're seeking and they're getting at a disproportionate scale than they ever would have gotten in the ancient world from the digital world. So if men are you, you mentioned in the book that youth and beauty are one of the things that men look for as signs of fertility in, in the book, what is it that women are looking for?

[00:12:33] Dr. Duana Welch: Women mainly look for provision and protection, but having the goods isn't enough provision it's, it's not just the ability to provide and protect. It's the willingness. So let's say that a man has a lot of money. I've actually seen this in my client practice. Let's say, man has a lot of money. And he uses that to gain access to women, but then it turns out that when he finds a woman, he wants to commit to, he doesn't want to actually provide.

He just wants to have an ongoing relationship with this woman without actually provisioning her without making her feel safe. Women don't tend to feel emotionally safe if they're not physically safe, they don't tend to feel physically safe unless you as a man offer commitment. So I'm not just going to offer to protect you today.

I'm going to offer to protect you for the rest of my life. And potentially even after my decease, I'll have a life insurance policy. I'll leave you a house. That kind of thing. Women don't tend to feel safe without that. So again, the modern meeting context is not really queuing the behaviors from most men that women or that women deeply connect with.

And a lot of women who say, oh yeah, I'm fine with casual sex. Some of them really. But research would indicate that three quarters of them, what they really mean. And again, they're not necessarily consciously aware of this, but what they mean at an implicit level is I'm going to give you sex in the hopes that this starts a relationship where you want to commit to me.

So women are looking for commitment that indicates that this provision and protection will be ongoing. They're looking for love, which is another indicator of that. And they're looking for generosity back to the guy who does it, he can provide, but he doesn't really want to. I had a client who she gave me permission to put her story in my books.

And so in the book, she's called Diane. That's not her real name, but she was proposed to, by a man who had lots of resources. And she had a couple of kids that were very young. And this guy asked her to get married and she called me and said I have some doubts and I don't know where they're coming in.

And I love him. I want to have a life with him, but there's just something in me that is resisting saying yes. And I said, anytime, you've got a gut feeling, you need to investigate that further because your intuition is a finally evolved mechanism. That's there to save you any, any problem that your ancestors had with survival and reproduction, probably your intuition has some inkling about protecting you on that dimension.

So I want you to ask him some questions. And one of the questions I want you to ask him is what would marriage look like in your ideal world? How do we deal with paying for health insurance. How do we deal with the mortgage? How do we deal with my job, your job? Those kinds of things. And so she asked him and it turned out that he just thought that he would just go on living like he was living and she could have the benefit of living in his home, but he wasn't going to provide health insurance.

Although his job gave him health insurance, it was not going to cost him that much more to provide it. And he had all the resources, it was a button off of his shirt, really for him to do for her and her children, but he didn't want to. And she turned him down. She eventually accepted a proposal from a man who had far, far less, but wanted to give it all to her.

And so after this, I started asking my students here's scenario A and here's scenario B, which woman do you think was why. The woman who chose the man who had a lot of resources, but would not give them the woman who chose the man who had few resources, but devoted them all. And I've never had a semester where students said, oh yeah, go for the guy with lots of money.

Who never shares it. 

[00:16:21] Griffin Jones: Yeah. Evolutionarily. That makes sense too. You had a know there was one partner Genghis Khan, or it had everybody, but it probably wasn't a lot of security for all of the women that Genghis Khan reproduced with over the years. Right. But at least whoever was in spots tend to 458, probably didn't, but it makes sense that it's someone having a mate that was willing to procure resources and, and to, to share those resources, it seems like more of an evolutionary advantage.

[00:16:55] Dr. Duana Welch: Absolutely. And the thing about Mr Khan is that a lot of those women didn't have the choice, right? Rape was rampant. And a lot of those women wouldn't have had the choice, but among those who did have a choice moving it to a whole different era, there were Beatles babies. There were women who tried to have sex with one of the Beatles, for the purpose of getting pregnant.

Sometimes a woman will roll the dice for a man who she knows will not commit, will not provide, will not protect. She has the sense. And again, this is not conscious. Mating psychology is rarely conscious men don’t say say, Hm, her waist to hip ratio is 0.7. Therefore she is both fertile and fecund. And I shall tap that.

They don't say that they just know what they want. Women just know what they want. They want one of the Beatles, but they don't realize it's because a man who can distinguish himself to that degree probably has superior genes to cast forward. And her children have better chances of success in life, even if he doesn't offer provision of protection.

[00:17:56] Griffin Jones: And you talk in the book about the difference between long-term and short-term mating strategies. And I do want to dig into that. I just want to make sure that I have it correctly. So men are seeking fertility and fidelity is that that's their two big things and youth and beauty are signs of fertility.

And is that my rights so far? 

[00:18:15] Dr. Duana Welch: Yeah, absolutely. It's not the only thing they're seeking, but if men were left only to their urge, that would be with them going.. 

[00:18:24] Griffin Jones: And women are seeking above, above other things, including other things, but above other things, provision and protection. Is that the right way of look recapping that?

[00:18:35] Dr. Duana Welch: Yes. Unless a woman is in short-term mating mode, in which case she's going to look for things like fame and, and extreme fortune. There's a study from 2013 by researcher and Carrie Getz, and she found that women in short-term mating mode look for a man who flashes a lot of cash right away.

And who's unusually good looking, but women in long-term meeting mode, they're looking for men, who's offering for the long-term. And of course, those of your listeners, they're dealing with people who are trying to have children and are having difficulty accomplishing that these are people presumably in long term meeting mode or people who've found their long-term partner.

And so these women are looking for provision and protection, for sure. 

[00:19:17] Griffin Jones: So either they, some of them are coming later because it took them longer to find that long-term partner because of some of this, or some people have said either I am not finding a term partner or it's just not for me.

And, and they're coming to fertility specialists as single wound so that they can have their children. And so this is probably impacting them in some either they decided to, they just said, well, that's not for me, or it took a while. And so I want to talk about the, the short term, the differences in short-term mating and long-term mating for men and women, because I suspect that our digitally lives are pointing more towards the short term as they do, is it doesn't many things. And you say in the book that men's short term and long-term mating strategies run concurrently until they don't. Right. Whereas women's and short-term, and long-term mating strategies are different from the beginning.

Can you talk about that? 

[00:20:22] Dr. Duana Welch: Sure. Well, one of the points is something I alluded to earlier, which is a lot of times when women claim to have a short-term strategy, their biology kind of hijacks that and turns it into a long-term strategy. It usually doesn't work. But for example, a scientist named Townshend found that women in short term, mate-ships, they were in a friends with benefits situation when he asked them is this partner right for you?

The women by and large said, no, that's why it's a friends with benefits thing. This is not my right long-term partner. And then when he asked them, so are you emotionally connected to this person? Is it difficult for you to maintain your emotional distance? 75% of women said, yes, I'm getting attached.

Even though I don't want to. Now a quarter of women, they were able to just walk away whistling a happy tune was fascinating about the study is the results were exactly opposite for men. Three quarters of men said I'm not having any problem at all. Maintaining my emotional distance one quarter of men.

 What I'm getting attached, even though, probably not a good idea. So, the odds are in favor of women when they pursue a short-term strategy, having some kind of long-term angle, whether or not they're conscious of it when women pursue a purely short-term strategy. A lot of times it's because they don't have the ability to pursue a long term strategy.

For example, after wars, if most of the young men are deceased and they're just a handful of men left that they could procreate with, they'll make the compromise rather than having no children ever they'll make the compromise. And they'll be the other woman, they'll be the side piece, women who have no access to resources of any kind and their desperate poverty, they will choose prostitution or it'll be forced upon.

One way or the other, and it's not because women love prostitution. I always find it interesting that women are so denigrated as if they thought, what I'll do. I know I'll become a sex worker. There are women who do that, but it's really, really unusual. So one of the first things to acknowledge is that our current landscape is exploiting only certain aspects of mating psychology.

Yes. Women and men alike, both have short-term and long-term strategies. And whereas women's is usually long-term even when they say it's short term, men's really does split into long-term and short-term the vast majority of men want to get married. They want to have a full commitment. They want to have a family.

In fact, men who are divorced are even more likely to want these things than men, than women who've been through. So it's not like they say, oh, once and never again. I'm never getting married again. They normally see the advantage to full commitment. The problem happens when we extend and these are, these are my words, but they are based on studies that I'm thinking of right now, when we extend adolescents to a point where people can reach their thirties without needing to seriously contemplate settling down, then you wind up with a phenomenon where women are in this bind of trying to find someone to get to know well enough to make a reasonable choice, to have a child with and someone who will commit to them.

And if they keep having sex right up front. And if men keep doing that, a lot of times the emotional bond that they need in order for it to make sense to have children with this person, it doesn't form. So women are in this circumstance, like the women in war. Who am I going to pick? What am I going to do here?

And so a lot of them do turn to sperm banks. I think that is an increasing phenomenon. I certainly hear from women who ask me, is that something that I should do? I kind of feel like I should take care of motherhood on my own, and then look for a partner. Cause I'm running out of time. And guys don't like to be looked at like, you're my last best hope.

And then men, conversely, sometimes they don't realize until their fifties that they would really like to settle down. And the problem with that is women don't tend to trust men. Who've reached a certain age. Who've never gotten married. They will say to me, I'll never date a man who hasn't at least been married before.

I just won't. And so men have prime time also for committing, maybe not so much for a biological reason, but for the reason that they do pay a penalty actually for waiting quote unquote too long to make a marriage choice. I would say that the. The price for this seems. And I don't know if studies on this, this is my experience with 20 years of clients.

What I do is I help people find, commit to and thrive in healthy long-term relationships based on with the basis as science being for my advice rather than just my opinion. And so what I find is that once a guys had, I don't know, 40 to 45, it becomes a bigger challenge for a couple reasons. Number one, women think, well, gosh, he's so much older than I am.

I don't know if I want to spend that much time on the backend of my life with him being that much older than I am or I think he must just be a Playboy. Why has he never settled down before now? Or they'll think, maybe he doesn't have, there's something wrong with him.

He doesn't have the ability to make a commitment. It's not a Playboy. He just, there's something that that's just off here. So women don't tend to trust. But I do think that's one reason why fertility specialists see women and men past the traditional age reproduction probably on a an increasing basis is men.

Who've waited a long time. Now they their fertility declines as well. Of course, everybody in your audience will know that it's not sharp, like women's, but there is a decrease and then women who need their, in a time crunch. They have to find somebody if they're going to ever do this. 

[00:26:05] Griffin Jones: And so there's a mating cost to men waiting too long to, to settle down to.

I kind of felt that way at age 34, like in the scene of the movie where the giant door is closing any rolls underneath that at the last moment, I kind of felt that way. So, okay, this is happening where people are wondering, well, I've gotten to this age, should I even partner? And what about you mentioned the Beatles baby phenomena as a short term meeting strategy for women.

So in the book you say that women will look for when they're truly in a short-term strategy, versus when they're in a long term strategy, they will look for different characteristics, right? That the type of man she might marry is not the same necessarily the profile of man that she would hookup with on a one night stand.

Can you talk about that? 

[00:26:53] Dr. Duana Welch: Yeah. Women, the biggest predictor of whether a man can have extra pair of sexual relationships, what you and I would call a affair. The biggest predictor, whether man's going to do that is actually not whether he's happily married. It's whether he can, the biggest predictor of whether a man can get women, even after he's committed is how good-looking he is, how famous he is.

 Is he rich, famous? And good-looking whoa, that guy is going to have a lot opportunities, cheat, especially if he has a ton of sexual experience already. And if he travels for work, those are cheating's five usual suspects. If it's, and a lot of times that guy is just one guy. Like there's a guy who has all of that.

And so a lot of times women kind of don't trust that they would love to have a short term fling with that guy, but they know that all the other women would love that as well. And at a gut level, they're a little worried about committing to a man like. I was recently watching a lecture by Dr. David Buss, who is one of the 50 most influential psychologists alive today.

And one of the most important thinkers and writers in evolutionary psychology specific to mate selection. 

[00:28:09] Griffin Jones: The author of “Why Men Behave Badly” is I think his most recent book, or I dunno if it's most reason, but it's one of his books. So please, please go. I think I found him originally from you. I found a whole bunch of great people from you, but, but please go on about Dr.

Buss's work. 

[00:28:27] Dr. Duana Welch: Yeah. Thanks. Yes, his, his big recent book is “Why Men Behave Badly”. His timeless classic is the evolution of desire. He's got a book called “The Murderer Next Door”, which is about a toxic jealousy and where it comes from an, our ancestral past. He also was the author of the first respected and widely used evolutionary psychology textbook, and it's in multiple languages all over the world today.

I think it's in its sixth or seventh edition now. So he's a huge thinker in this area. Not going to lie. One of the best moments of my life is when he endorsed my books. He is the author of “Why Men Behave Badly”.

That is indeed his most recent tome really it's all his books just make my jaw drop. They are so heavily science-based, he's done research in 37 different cultures and countries. The research continues right up until today. And one of the things that he finds and that he said in a recent lecture of his, that I attended, and which is covered also in the book, you mentioned women behave badly is that men will frequently it's not all about.

It's not all men that rape. It's not all men that are predatory. It's not all men that cheat. It's a few, but they really get around. And one of the biggest predictors of whether man is going to be one of these guys, is, is he extremely powerful and wealthy? He is very likely to do that. Now, women seek those guys out for short term liaisons.

It's not just that these men try to get sex it's that women offer them sex. So for example, I've worked with men who want to be faithful and are faithful, who they save my life, if I tell other men about it, they hate me because what happens to me on the daily is women come up and say, how about it really?

And truly it's a world that most men can never imagine, but some men inhabit that world and women usually don't want to marry those guys because they know that men inhabit this world. They know they're taking a big risk when they choose this man. 

[00:30:29] Griffin Jones: Contrast that with men's short-term and long-term strategy, we tend to run concurrently, right?

Oh, she's attractive. She's nice to talk to. It's not like a different profile of other, other than one being a lot wider than the other, I suppose. But can you talk about what men's short-term mating strategies? 

[00:30:49] Dr. Duana Welch: Oh, I certainly can't actually the distinction between women's long-term strategy and women's short-term strategy is actually pretty narrow women.

See somebody better looking and with more resources perhaps for the short term, but they. So they'll accept somebody who's maybe not as tall, maybe not as good looking, but it's committed as a provider and protector for the long term, but their standards are actually pretty high for short and long-term mating because a woman ancestrally was stuck with the results I.E. Kids for absolute ever, which might not be very long if she died or her family stoned her or whatever, it could cost her her life to make a short-term move.

So even when women are in short-term mode, they tend to be very cautious men on the other hand, and I'm going to quote Dr. Buss here. He says that their strategies are sometimes a bit smoley low when it comes to a short-term partner. Their standards for a long-term partner are just as high as women's are a man's standards for a wife are very high indeed, but a man's standard for a hookup can be a woman who's not conscious.

A woman who is a mentally challenged, who actually has a developmental deficits, a woman who does not have good social intelligence, a woman who maybe is not even all that attractive for short-term mating men standards are really, really low by and large. Now for longterm meeting, men standards tend to be, no, they want youth and beauty and they want somebody who shares their values and will raise children well, and we'll get along with their family and has good friends of her own and is mentally healthy, et cetera, et cetera, et cetera.

[00:32:26] Griffin Jones: You talk a little bit in the book about how one, if a man, a man can be pursuing a long-term, maybe this is what I'm thinking of. And please make the distinction is that a man will be, can be pursuing a long-term strategy, but then he can, he will abandon it for the short term strategy of if that's what he's pursuing a woman with all the features that you just described. But there's the opportunity for a short-term mating strategy to be executed more quickly. And so he'll abandon his long-term mating strategy for that is that one a fair characterization? If it isn't please correct me?

[00:32:58] Dr. Duana Welch: No, you're absolutely right. So, because men's long-term and short-term strategies tend to be operating at the same time. When women meet a man, if a woman is what a man is looking for, or very close to what he's looking for, if they have sex right away, a lot of men will not be able to emotionally connect.

So I've worked with men who have said to me, and this goes right along with the science I've worked with men. Who've said to me, Duana I really liked this woman and she's got everything I'm looking for. And. I was thinking about her for a long-term possibility. And now I just can't get interested.

And I don't understand why. And when I start asking questions, normally there's a profile. Normally it's the case where this guy has had pretty easy sexual act access to women in the past. So this is my hypothesis and it is not proven. I just want to tell you, I'm basing this on science, but I'm making a leap here.

Okay. My leap is that the more short-term partners a man has had, the more difficult it is for his dopamine levels to rise to a point of falling in love. The reason I say this is, I know for sure studies show that men who have immediate sex with a woman often do get emotionally bonded. If the man is a virgin has very low social status or has very few sexual partners in his past, very few.

This makes me think that the opposite is also true. And my work with clients has, has borne that out. What I tell these guys is, look, it's not like you set out to be a so-called cat. You actually had intentions toward this woman that were of the long-term variety, but what your mating psychology did is it shifted her from the Mrs right category to the miss right now category. And because this is not a conscious decision, you probably don't have a lot of control over shifting it back. So what I would recommend is either you go to a dating scenario with the same woman where you stop having sex with her, I've never seen a man take this advice, but.

But it is a possibility of something a man could do to try to put the toothpaste back in the tube. He could stop having sex with her, but continue courting her and see if his dopamine levels can start to ramp up to the point that he actually falls in love, or he can stop seeing her. And the next time he finds somebody that, and by the way, stop having sex with other women too.

You want to increase your motivation for really finding Mrs. Right? And the motivation is a lot more increased if you stay thirsty. My friends in the word of the commercial and the words of the commercial. So stop having sex with anybody, but you, and start looking for Mrs. Right? When you find somebody who you think is a possibility where you're attracted to her more than just for her appearance, you're attracted to her personality.

You think that she has what you're looking for in a long-term partner court her until you are deeply in love before you attempt to have an orgasm with her. 

[00:36:00] Griffin Jones: So people are going to be asking, well, when are you going to talk about same sex couples, Griff? When are you gonna ask about transgender? I am going to ask about those things, but if I had my way, do I know this would be a five and a half hour podcast, because there's so much that I want to ask you.

And the reason I've been digging in on the short term and the differences between short-term and long-term mating strategies is because if the technology that we're using right now is causing us to, or is it empowering one over the other? It would explain for a delay in finding long-term partners.

And it would be that partly makes sense for why people are coming to see fertility specialists later in life. But I want to continue on this, this point that you just made of, of his dopamine might not be raising enough in the case of. If he's pursuing a short-term meeting strategy from porn or Tinder , or all the things that, that exist in society now that either didn't exist as much or didn't exist at all a few decades ago.

Then is it possible that it's part of a social construct? So I think when people think of that, they think of, oh, that's the old double standard is that he can sleep around and that women can't and I suspect that that double standard, that social contract arose from this primordial mating behavior.

But can you speak to that at all? 

[00:37:31] Dr. Duana Welch: Sure. I hate the double standard. I mean I'm a feminist. I believe women should have all the same rights and opportunities that men have. And it's not the world we live in yet, but I do know where the double standard comes from. And I don't see it changing anytime soon.

One of the re one of the reasons for the double standard and quite possibly one of the reasons that men lose interest in she, who was easily obtained sexually is because of something called paternity assurance. Fertility specialists are a new phenomenon, especially well, in any scientific sense, there have always been people who claim that they could do this with your bed position but fertility specialists, those are new, right.

And for paternity tests are new, but our mating psychology comes from a time that is thousands and thousands of years before those phenomena. And therefore a mating psychology exists as if it acts like those phenomenon kind of don't exist. So men are biologically as well as psychologically primed to avoid making a long-term commitment to a woman who might put his genetic line at risk.

So for example, men have what I call super sperm. They have sperm. There's a little bit, there's some controversy about the first thing I'm going to say none about the subsequent things. I'm going to say. There's some controversy about whether there are sperm that exists for the only purpose of strangling other men's sperm.

And those firms would definitely not exist if sperm competition never happened. If women were always faithful, if women never gave it up for somebody else. Okay. So maybe those farm exists, maybe they don't, some studies find it.

[00:39:13] Griffin Jones: So the andrologist listening. There's a hypothesis for your next abstract.

There's for the next study that you're going to do. Maybe there's some andrologist that's studied that. So we're listening. Okay. So there's potential controversy with 0.1. What are the subsequent points? 

[00:39:28] Dr. Duana Welch: Well, men have they have larger testes than any other mammal per body size. I mean, the reason for that is you don't see that.

For example, with gorillas, gorillas have no mate competition at all. They have a harem there. They, all, the Silverback is the only male with access to those females. They have phenomenally low sperm counts. They have very short penises because they don't have to please a female they've got access regardless of what she feels about it.

Human males are not in that position. They compete against other males. And when they're off providing and protecting, their woman could be with somebody else voluntarily or otherwise. And men can't control the or otherwise portion of it. There, there can be a war where men use rape as a, as a threat against men, which they do still today a lot. You can't control that, but what you can control is she likely to put my genetic line at risk physiologically. One of the ways men protect against that is by having a higher ejaculate, higher sperm count per ejaculate than any of the other primates and mammals. And their testessize per body sizes, enormous.

They also have something in their semen that this blew me away. The first time I heard this, I thought semen was sperm. I thought, why did we not use those terms interchangeably? Well, because as probably everybody listening to this knows, but I didn't know because this isn't my field. Most of what's in semen is not sperm

most of it is stuff like sugar, like a sack lunch that the sperm carry along with them. So they can have a snack while they make their way to the egg. ost. And, but there's a whole lot of other stuff too. There's dopamine and there's oxytocin. There's this cocktail of chemicals that are easily absorbed through vaginal walls that create a woman's attachment to a man. Gordon  Gallup Jr.did research a few years ago that showed that if couples aren't using condoms and they're having sex at least once a week, if a man is ejaculating into the woman that he's with, the jacket has so many mood boosting properties that it's as effective for most women as an antidepressant. So what's happening is that's yet another physiological mechanism that men have to keep.

Women from putting their genetic line at risk. She feels good when she's with me, she's not going to stray. So most people find this, you know, oh, oh, I get, just have to tell you one more Griffin. Cause this one really freaks me out. So if you separate men and women for two weeks and other men and women are together for those two weeks and the men and women are together and in a committed relationship, you just say, have sex the way you normally would.

And the men and women who are apart they're apart for two weeks and you say, you can masturbate as you normally would. Then at the end of two weeks, you have these couples, you say, okay, we want you to have sex on day 14. So however much you've had sex with your partner in the interim, we want you to have sex on day 14 men, who've been with their partners the whole time, have a much lower sperm count per ejaculate than men who have been without their partners the whole time, even if they masturbated the same amount that these other guys had sex with a woman that.

In other words, something freaky is happening where a non-conscious process recognizes. Oh, she could have been with somebody else. I will pump up the volume. Literally there will be more sperm in my jacket than if I had been with her the entire time. 

[00:43:17] Griffin Jones: So there's so much evolutionary behavior and genetic responses to protect the genetic line of the mail.

That perhaps the reason for the reason for the double standard is because I've heard you say before, and this is an on this podcast. We have to put an asterix of, not anymore with donor oocytes sites, but that, but of course, prehistorically that the woman knew whose baby it was no matter how many men she slept with it was hers.

Exactly. And so up until assisted reproductive technology with donor gametes, which is only decades old. That's always been the case.

[00:43:58] Dr. Duana Welch: Always.

And so there is a double standard. You can, you can count on it that any time our bodies have protected us from, from somebody sleeping around to such a huge screaming, I just gave you just the tip of the iceberg on the data there, right?

Men's bodies do a lot to make sure that they do not put their own genetic line at risk by choosing the wrong long-term partner. They do a lot. Now you can, you can guarantee empty it. They have emotional mechanisms for the same thing. And one of those emotional mechanisms is they just don't trust women who sleep with them right away not to do it.

The same thing with other men, they just don't. When women say I've never done this before. Men do not believe that. Even if it's true, when women say you're different, you're special to me, men don't buy it. Even if it's true. I work with women all the time who say, I really felt like this guy was so special and that's why I had sex with him quickly because I know that other women will do it if I don't.

And that's the only reason I did it now, he's not into me anymore. And I feel terrible about it. And he doesn't believe me. And he's not into me at a, you know, I don't love this, but I know where it comes from. It's not fair, but it is the way it is. 

[00:45:08] Griffin Jones: So why do we suspect that men are not pursuing long-term mating strategies?

Well, if, if that is the case, why do we suspect that on the Tinders? Is that just because that's, what's available on, the Tinders and the Bumbles and all of the places to, swipe, right. It's like, well, I don't believe that. Or my, not me consciously, but my subconscious, all of my evolutionary biology is telling me that this is not a good fit for protecting my genetic lineage.

And therefore, I'm just going to pursue short term mating. Is that, is that what we suspect is happening? 

[00:45:51] Dr. Duana Welch: Yeah. I mean, that's a big question with a lot of answers. It's not going to be either or it's going to be a both and kind of scenario. So Phil, Zimbardo pointed to research. I'm going to say about 15 years ago that showed that the average 14 year old was watching about 14 video clips of pornography every day, every 14 year old boy girls were not doing this boys were, and he was able to correlate that with boys desire for commitment in the future versus prior generations of boys had felt. And what he found was that boys did not have the same objectives with regard to marriage and commitment that they had had in prior generations, based on the sheer amount of, men have short-term and long-term mating strategies happening at the, at the same time.

But if the messaging they're getting every day, 14 times a day says short-term is better. What do you think is going to have the greater influence? So part of what's going on is there's always been pornography. I mean, you can go to Pompei and you can see it on the walls. There's always been porn, but it's never been so accessible.

And Tinder has really accelerated that the perception and. The actual reality is that men can get on Tinder today. And many of them can get a sexual partner tonight and never see her again. So again, men have a short term and longterm program, but when you have sex with a lot of different people in the short-term program, the short-term program is what gets activated more and more and more.

And I think this is why, so the average age of marriage at the time of the American revolution, do you have any guests of what the average age of marriage was for men and women? 

[00:47:27] Griffin Jones: I'm going to guess for men, it was 20 and for women, it was 17 at the American revolution. 

[00:47:35] Dr. Duana Welch: So I'm impressed.

I'm impressed because most people actually guess way longer than that. So the average age for women was 22. 

[00:47:44] Griffin Jones: Okay. So I was young. All right. So I guess I have no idea when, because all I'm thinking is like, grandparents' age. And so I'm extrapolating a trend that may have not continued that far.

Okay. But so 22 for women. 

[00:47:56] Dr. Duana Welch: 22 for woman at the time of the American Revolution. Yeah. And women were needed at home to help take care of the younger kids. It wasn't a boon to get all your 13 year olds and 17 year olds, married off. Well, men needed to have some resources. So they were usually considerably older than.

So they would often be more like 24, 25 ish. 

[00:48:17] Griffin Jones: Is that similar to what it was around world War II? Did it just not? was it stable at that for centuries was?

[00:48:24] Dr. Duana Welch: It was stable for a long time. And then an interesting thing happened. I'm glad you brought up World War II. We tend to have this idea that probably because of our grandparents, who grandparents, great grandparents who married or found their person in World War II, that people married in their teens at the time of World War II was the only decade where we have records, which we've had records since the American Revolution where mainstream Americans married under the age of 20, the average age for women at that time was 19.

And for men, it was just about 20 to 22. Since that time we didn't just go back to where it was at the time of the Revolution. We went way beyond that. We went to, now the average a generation ago, the average had increased to, I think, 27 for men and 24, 25 for women. And now it's in the thirties.

And again, why are you seeing more people who need help with fertility? Because the average person does not understand how sharply women's fertility declines and how quickly that. They don't understand that the time horizon is in fact not, it's not normative for women to easily get pregnant.

[00:49:32] Griffin Jones: And the people that understand it are listening to this show. No, no one understands, like we were never told about that. , I mean, well, of course we're to some like very peripheral level, but in terms of like, I hear so many of my peers that are like, oh yeah, like I'll think about having kids, like when I'm like 30, 35, it's like, that's the end of the natural biological window.

And I think people really consider that. 

[00:50:00] Dr. Duana Welch: They don't even, I'm a developmental psychologist. And even when I would tell my students that, they would give me this stink-eye as if I made this up and I was harshing their vibe, don't shoot the messenger. I have nothing to do with these data other than reporting them.

So yeah, I know that everyone listening to this gets it right now there's this perception because men's, long-term, long-term mating. Psychology is not being prime very often. And because their short-term mating psychology is being continually primed, especially by swiping apps. And so is women's women are now doing something that they didn't used to do.

They're making decisions almost purely based on looks for a first meeting part of that is something I said earlier, that when you give people only one piece of information, they go buy the only piece of information they have, which is looks, but part of it is Tinder has also created the impression among women that there's an endless pool of potential mates.

It's done the same for them. And it's not just young women either. Here about here from work with women who are in their forties, fifties, and later who I have to have the talk where I have to say, please stop valuing appearance above these other lasting enduring qualities that make for a happy relationship.

Appearance matters only in so far as you match, it's called the matching phenomenon. People are happier if they physically match their person, but it's not just physical it's it's in terms of a lot of other things like their values and how they want to spend at least some of their free time.

And, and whether they like this other person, not just love them. Do they like this other person as a human being? So there's a lot that goes into it. And again, we're seeing a relatively new phenomenon here that I find really distressing, which is men and women are both selecting on swiping apps.

They're both select selecting for people who are 10% better looking than they themselves. In other words, they're not selecting for a match. So, what happens to men who consistently select for better looking women than themselves. 

[00:52:10] Griffin Jones: They get cheated, on dumped. I don't know what happens.

[00:52:14] Dr. Duana Welch: That's exactly what happens. Yeah. What happens to women who do that? 

[00:52:20] Griffin Jones: Same. 

[00:52:22] Dr. Duana Welch: They get played and ignored. So maybe the guy has sex with themonce, but they don't get a relationship out of it. They're not with the guy long enough to get cheated on and dumped So it's, it's really, it's, I long for the Halcyon days when, match and okay.

Cupid and E-Harmony werethe three big places you could go and you had a lot of information. People wrote paragraph after paragraph about what they were looking for. And there was all this information about what their value system was because people at that time research showed that people who met those ways were slightly happier than people who met any other way.

And the reason was they had enough information to make a good decision before they ever met in person. Now, the opposite is true unless you stick with those three sites. 

[00:53:05] Griffin Jones: So I does that also, so that explains the reluctance to match or matching first and foremost on someone's physical appearance.

But what does that mean for once someone is matched? It seems to me that, the actual getting to the date part takes more than take takes forever, or very often doesn't happen relative to the number of matches that occur. I don't have data just seems that that's what everybody talks about.

That was my experience. Do we have any data or information or trends on that of like, okay. Yeah. People have, they've been perhaps they're mismatching or they're matching first on physical appearance, but then like, why isn't this moving beyond that? 

[00:53:53] Dr. Duana Welch: So two phenomenon first of all, I don't really know the answer.

I'm going to make a guess. I'm always going to tell you what I'm guessing. I'm guessing based on what I do know about human mating psychology, but I don't know of a study that speaks specifically your question. I'm guessing that right now there's this kind of bifurcated. Reality where the men who are looking for a long-term partner who are on a meaningful site to try to accomplish that are having a fairly difficult time, attracting someone unless they're already very good looking.

And I'm having, even for the first date, I am also hypothesizing that men who have a modicum of good looks, especially if they're also tall, are having no difficulty getting, it's not even a date, just sex why don't we just Netflix and chill. They never take anybody to. So I'm guessing it's kind of, bi-modal distributed that way, that people at the men at the top of the looks well and height, demographics, they're not having that hard a time.

And the other guys are, I certainly see this in my practice. And I talk about, Hey, here's how you succeed. If the odds are against you and here's how you succeed. If the odds are for you, because keep in mind the guys who the odds are in their favor, where women will just give it up on the first date, the odds still aren't in their favor.

The men who hire me want to get married. If women are having sex with you all the time, the first time that's not actually helping you get married from what I've already said, otherwise these guys would never hire me. They have access to endless amounts of sex that would never hire me if that was all it took.

And they do a lot of them hire me. So, I don't know how long it's taking. I do know that there are some strategies that men and women alike can use to make sure that they attract worthwhile partners, not just partners who look good and where they can keep it from becoming a pen pal situation.

Nobody wants that. Nobody wants to just endlessly text message except for players. And guys would self-esteem that or women with self-esteem that so low that they're afraid to actually ever meet anybody in person, but that's not most people, most people ultimately want a genuine connection and you don't get it over text and you don't get it usually on a swiping app.

[00:56:13] Griffin Jones: So what are some of those strategies that, that people can use? And also you say most people don't want that. And I agree with you, although my hypothesis is, as the generations are younger and they get less comfortable with any kind of in-person or eye contact type of contact that, that anything starts to see or anything above whatever their baseline is.

And if their baseline is being in their phone by themselves all the time seems invasive. So it you'd say our DNA hasn't changed in the last 200 years, but but our technology has, and so if I were courting someone 150 years ago, I might go knock on their door and in my suit with my flowers and, and say, hi, I'm Griffin.

But if I did that 50 years ago, like in the seventies, people be like, what the heck is wrong with that weirdo? And certainly if I did it today, it'd be like somebody, somebody get that gut. Somebody send that to prison, if that was the first move and so what would have been I remember in 2008 called.

A young woman on a foot that was like, that was like, cool. Like that meant you were, you weren't afraid you were, you were going to call and it was bold and it was gentlemanly. And then in 2013 it was like, what the hell is a phone call? And so I can envision a generation where even texts seem invasive.

And so I'm really interested in these strategies. And how do you layer them? How do you make them gradual? I guess if, if that is the result that people are so distant from it from a starting point. 

[00:57:51] Dr. Duana Welch: Keep in mind, I have an entire book about this, so we won't get to all of it. But to, to go to your point about, about texting and about the way that, again, our evolved psychology is interacting in brand new environments and it's, it's having to try to adjust to those environments.

I don't know which way things are going to go. And I'll tell you why the generation that is just now coming of age, live through a pandemic  as did all the other generations still living, but they came of age during that pandemic. I didn't, I'm 53. All my ways of being were jelled. By that time I met my partner during the pandemic.

I did it intentionally because I knew that I had a very easy way to keep everybody at arms length for as long as I wanted win-win. So I had what I call a tipping point. One of the ways is created tipping point where you get rid of people who just want to play the field. And the only people left on the field are the ones who are serious.

And one tipping point is not going to get close in six feet until it looks like we're going to find. Okay. I don't know if today's young people because they have been in a scenario where they couldn't get physically close to anyone, whether that is now so prized, that they are willing to get out of their comfort zone and interact with the world more and more, or whether that has become so depressing that fear of public places, fear of other human beings, fear of contact has been exacerbated, or whether both of these things are true, whether it's by bi-modal with some people going one direction and some people going the other direction, I suspect that's what's really happening and people will find a way because lonely. They will ultimately find a way. I do know that pandemic increased people's desire to have a committed relationship. I do know that the trend toward being casual declined during the pandemic. I don't know how long that decline will last in the face of the technology we've been discussing.

And the trend that's been happening for more than a generation now towards short term mating programs. But one of the things that people can do is they can use a phone call and not a text. And you are absolutely right. Phone calls have been seen as bizarre and overstepping for quite some time now, but here's the deal.

What are the things we know in business is you don't even necessarily have to have a better product in order to succeed. You just have to have a different product in order to succeed. And this is also true in the world of mating. You don't necessarily have to have a better way of doing things in order to succeed, to succeed.

Although it helps a different way can also be just as helpful. So for men who are men are still in the pursuer role by and large, even now, men are the ones who reach out first. They're the ones who make the plan. They're the ones who kind of are the engine behind any actual courtship and not just hooking up, but they're also usually the engine between her surrounding cooking up men are therefore in a really good position to differentiate themselves from all the other guys out there.

By saying when they are meeting somebody, whether in person or more likely virtually, Hey, I'm really enjoying talking with you. I know that it's so 1999, but I would really like to talk to you on the phone and get to know you better. That way. I find that it's a much better way to get to know somebody than a text messaging.

It's a good differentiator. It helps men, especially who aren't, maybe the guy that women would look at an automatically choose I'm the guy who has a lot going for him, who everybody tells him, he's such a great guy, but maybe he's not super tall. Maybe he's not extremely handsome or really wealthy.

Those guys are really helped by standing out from the crowd and offering women. What women's mating psychology still wants today. Long-term commitment, provision and protection over the long haul players, love, texts. They can send the same text message to every woman in their digital address in their digital address book, they can, they can search to their whole contact list.

If they've got a special contact list, that's just women who are single. They can literally send it to all of them. And I watched the Tinder swindler. Some of them do, they can, there are guys who swipe right there. There are actually apps that help men swipe right on, out on everyone. Who's in their given area, in the hopes that any of these other people will swipe right on them.

That's how low the bar is for short-term mating. So when a man actually makes a phone call, here are things that he's doing that show women the seriousness of his purpose. He's making a plan. You don't just call a woman on the spur of the moment anymore. You have to make a plan to call her, right. People don't answer their phone.

The second thing is you have to think of stuff to say. It shows your social intelligence. You get to display that on a phone call. You get to move through your social anxiety. Again, love requires bravery and most people ultimately want love. It requires bravery. Women are still looking for a hero. They're still looking for someone who's brave.

They're still looking for someone who devotes himself to her and not to everybody else. And so this shows that, and it, it keeps the pursuit going, much as men enjoy having sex right out the gate. They love pursuing a woman who they have at have to work for men. Love it. Watch how little boys.

When little boys play, they play at being the concrete hero of the world. They don't just play violence for the sake of violence, unless they're a little sociopaths, they play at liberating Ukraine or whatever it is they play at saving the world. Boys are not violent. They're heroic. They love to be the hero.

So when they do it this way, they get to start something heroic. Make plans, ask a woman out a whole week in advance. What? There's a lot of women who will disappear. Good. Those women do not have the goods to make it for the long haul. If they think you're a freak for asking about a whole weekend in advance.

Let me tell you the women who are serious in their purpose, they love it. When you ask them a whole lot out a whole week in advance, it shows that you're different from the other guys

[01:04:31] Griffin Jones: So I think I could spend an entire, yeah, this is why you have a book and it's called “Love Factually”, and we're gonna link to it.

And its in the show notes it's and everybody should pick it. You should pick it up to know what's going on with your patients, but you should also know it. Pick it up to know what's going on with your friends and relatives who are single. And if that's you, it will change your life. This book, I want to ask about same sex couples, because the part of the reason why I haven't up to this point is because there is a lot of overlap between what women who are attracted to women want and what men who are attracted to men want as men attracted to women and women attracted to men.

But there are some differences, and can you talk a little bit about that?

[01:05:09] Dr. Duana Welch: Sure. Weather and I'm going to talk about transgender to whatever gender orientation a person has evidence is mounting that their brain structure mimics their gender orientation. So people who've grown up thinking I'm a guy who don't have the external genitals of guys.

If you look at their brain scan, the brain has guy and they value the things very often that that guys value gay men are men. They value youth and beauty men. It's, it's easier for me to talk about men's preferences than a women's and we'll get white to why in just a second men value youth and beauty.

Even if this guy is choosing other guys and therefore they're not choosing fertility necessarily, they're not choosing someone that they can procreate with unless they adopt or have a surrogate or something like that. And if you, if you don't believe me, look at the only groups of people who are not afraid of losing their looks straight men, and a lot of lesbian.

People who want to appeal to women, usually aren't that afraid of losing their looks. People who want to appeal to men usually are I'm 53 and you're not, I'm still trying to look. I think I would age past that, but I'm still making an effort why? Well, this is why. Okay. So women, it's a little more complicated because there are women who self identify as them lesbians.

And there are women who self identify as Butch. And you can even look at third-party ratings where you ask people, do you think this person is lesbian or straight? And do you think this person is Butch or femme? And people will identify these strangers the same way that the stranger self-identify fem lesbians are identified by others as.

Butch lesbians are identified by others. Who've never met them as Bush. And what's fascinating is they're mating. Psychology tends to go along with these self and other generated designations so that women who are identified as femme tend to have a more stereotypically feminine mating psychology, where they want a partner, they want a woman, but they want a female partner who's going to provide and protect.

And who is going to do that on an ongoing basis. Women who self identify or are other identified as Butch lesbians tend to have a more masculine mating psychology. For example, they're much more likely to enjoy watching pornography and to do that reliably and routinely. And to, if you ask them how many sexual partners would you like over the course of your lifetime to give a number that's in keeping with what a straight man would say.

So given that the tips that I've been giving, if you are. Femme and lesbian, you can pretty much use your mating psychology as a guide toward Butch lesbians. And by the way, it's funny. I often get feedback from people saying, well, I know women where it's two fems or together, or two Butch women who were together.

Well, what, that's not the way to bet you may know that, but that's why we have science and not just story. The trend is that fem women tend to wind up with Butch women and that gay men tend to trade either. They're both young and hot, or one of them has a lot more resources. And the other one has a lot more youth than beauty.

[01:08:32] Griffin Jones: I asked this because I think part of this has to do with like the, the discussion around this behavior has to do with the reason why people are pairing later. And and perhaps they do it at the peril of this episode is going to be launching at the same time. As I had an REI talk about third party family building, and he talked about how you, we don't just want to have LGBTQ plus friendly fertility treatment.

That's just a tack on. And I think people could say, you just tack that on at the end, you spent the entire 90, you spent 65 minutes talking about heteronormative relationships and then you just tack this on it at, at the end. And maybe that's because this is my show and I'm super interested in this.

And I have a guest on that. I just grill and I wish I could talk for five and a half hours. I'm not paying attention to time. And then the other part is. That I don't know. It's not immediately obvious where we say, okay, this is like, this is not the norm or we shouldn't be talking as though there's a default because I think you've painted the picture of so much science that that's out there that this isn't just something that we just learned.

We are 7 million years away from being chimps were 200,000 years away from being the, the last species that homo-sapiens broke away from. And so this is something so deeply embedded at us, but then it gets mixed with all of the ways that different societies and cultures can manifest it and come up with rigid rules that exclude people.

And it's not obvious to me where. Where it's like, okay, this is a default that we need to consider because if we don't, then we're not able to do the dance that every mammal has or every virtually every animal has. And we're not able to participate in that meeting ritual.

But if we been too far the other way, then we're excluding people where we're trying to apply to broadly general patterns. And so can, can you speak to that about about that in terms of how transgender people meet or may turn and participate if they really don't identify as any of, even the groups that you've talked about?

[01:10:53] Dr. Duana Welch: I cannot, because I don't know of a single study on it. The thing is that that recognition of transgender people as legit people. Sadly lacking, we're lagging behind as a world in this. And I we're going to catch up, I hope and believe. But when we talk about this being a heteronormative field, it is the vast majority of studies that have ever been done are heteronormative.

That said to the extent that we have data, it shows that however people identify their mating psychology will map onto the psychology that the gender that they feel most aligned to. And if they feel like they're not really aligned with either one, then who knows, maybe they can just set themselves free to for whoever they're into see if you can make it work out. I can't give a lot of concrete advice because. I'm so far out of my depth there, I don't have studies to go on when we, when we go that far. And that's my whole thing is basing anything I say on data, rather than simply my opinion. I will say that there's a gay matchmaker who makes all of her clients read my books and then sign a contract saying they're going to do what I said because gay men can, it's very clear who the gatekeepers are in sex it's women.

And if there's no women, then there's no gatekeepers and guys tend to have sex instantly. And therefore often not to form a deep and lasting emotional bond. And so she has, she realized after reading my books, Hey, my clients are saying they want to fall in love and they keep having hookups and they never fall in love, no matter how appropriate the match that I make for them.

And so she's had a lot better success. Since her male clients waited to fall in love before they started having sex. So what I'm saying is the evidence that we have points to the mating ritual is the same based on who you're looking for and who you are regardless of your orientation. 

[01:13:03] Griffin Jones: They're just really well.

She has given us so much to think about with regard to why our patients might be coming later in life of what they're doing when they're partnering, how our patients are, are partnering and what that means in terms of how they express themselves. How would you like to conclude to our audience? 

[01:13:23] Dr. Duana Welch: Well, I don't want to conclude the way that if you are listening to this and you are in your forties or beyond that, there's no hope for you.

I fear I may have given that false impression. The reason that I work with people who are having difficulties is because we overcome those different the odds of a woman, my age, finding a suitable romantic partner and making a permanent commitment are one in our 15 and a hundred. And yet I did it.

How did I do it? Well, I did it by using the science that I teach other people. That's how I did it. So there are ways to overcome this, no matter what obstacles you or your clients face. There are ways around them, at least where relationships are concerned. I can't speak to the fertility side.

That's that's on you, the listeners, but I can't speak to the emotional side. And the second thing I'd like to say is I answer all my emails. I see clients all over the world. So if you want to send someone my way they can reach out to me at lovefactually.co. And there's a spot to email me and ask about coaching.

And there's a lot of free content and links to my books. 

[01:14:24] Griffin Jones: Absolutely recommended. I recommend your coaching. I recommend your books. I recommend checking out. lovefactually.co, Dr. Duana Welch. Thank you so much for coming on Inside Productive Health. 

[01:14:36]Dr. Duana Welch: Thank you. It was delightful to be here.

131: Don't Strive for Inclusivity. Strive for Anti-Exclusivity. with Dr. Daniel Kaser

This week on Inside Reproductive Health, Griffin brings Dr. Daniel Kaser on the show to chat about the growth of the LGBTQ+ patients and third-party care. What it means to be inclusive to this group may surprise you! Little things, like patient intake forms, can make a huge impact on your ability to serve all populations.

Listen in to the full episode to hear:

• How 20% of Dr. Kaser’s patients are LGBTQ+ and how he is serving them well.

• Why REIs could potentially service only LGBTQ+ patients in some markets.

• Griffin drag Dr. Kaser into the battle about board certification and access to care.

• How state laws were relevant to Dr. Kaser’s practice location choice.

• How you might be wrongfully segmenting patients at intake.

Book Links :

Woke Racism by John McWhorter

“How to be An Anti-racist” by Ibram X. Kendi

Dr. Kasers info:

Website: https://rmanetwork.com/staff/daniel-j-kaser/

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Transcript

[00:01:00] Griffin Jones: We're talking about the growth of third-party and particularly LGBTQ plus patients as a practice area today on the show. My guest is Dr. Daniel Kaser from RMA Northern California in the Bay Area. Dr. Kaser talks about how he started his career in choosing even which state he moved to based on. The laws that were more accommodating to he and his husband at that time.

And then where they ended up moving to further that practice in the bay area, he did his fellowship at Brigham and women's he joined RMA of New Jersey in 2014. I want to say and then has recently been at the Bay Area and we talk about what is needed to. A third party program to serve LGBTQ plus patients access to care, and some things that surprised me about segmenting or not the patient populations within that broader patient population.

So I hope you enjoy today's show with Dr. Dan.

Dr. Kaser Dan, welcome to inside reproductive health. Thanks for having me great to be here with you. Good to have you on. We were saying before we started that it's like we've known each other.

This is the first time we've actually spoken face to face, so to speak via video. And when we were talking, you mentioned something that I thought would be interesting for the intro. One of the reasons why I wanted to have you on was taught to talk about serving LGBTQ plus population as a practice area and.

It was also, which is what you do now in the Bbay Aarea, but it's also part of the reason why you chose either your fellowship program or the first practice you worked with. Can you talk more about that? 

[00:02:51] Dr. Daniel Kaser: Yeah, absolutely. So I ultimately went into reproductive medicine and in fertility specifically to be able to help my own community in terms of other LGBTQ patients.

I knew at the time that for me to have a family, this was the path that I personally would be taking. And so I became interested in IVF early on in medical school, actually through, introduction to reproductive physiology by some really great professors and then had done some away rotations, even as a med student on like the infertility unit.

So I fell in love very early with cruel. The actual profession, but I was commenting that reflecting back that my husband and I got married in 2009 in New Hampshire. We met my husband. Dana is a physician as well. And we met in medical school. And at the time in 2009, New Hampshire was actually one of the only states in the country that recognized same-sex marriage.

And so what felt to be a very new kind of cutting edge thing now, fortunately it almost seems commonplace in terms of two men or two women getting married, but we had a church service and had a reception on campus and surrounded by dear, dear friends and family members.

And this was six years, I guess, before the Supreme Ccourt ruling to legalize gay marriage across the country. And so in choosing frankly where I did my post-graduate residency and fellowship training, we look to states at the time that allowed gay marriage and recognized our marriage.

And we ended up moving to Boston, Massachusetts, where I did OB GYN residency, and then stayed for fellowship training. And then at the end of my fellowship in 2016, had been looking for my first position out, outside of kind of the training here and still was looking for states that were inclusive in terms of marriage law.

And so I signed, I came to RMA for a number of reasons, but in 2014 is when I initially signed, signed contracts to come on. And at that point it was still like a year before the Supreme Ccourt rule. And so truly like if you look back at that, the places that I went to medical school, residency fellowship, even my first job it's informed by like policy and where I could frankly have rights recognized at the time.

And felt welcome and celebrated. So unfortunately here in 2022, it feels like a lifetime ago that there were places in the U S that did not recognize a relationship like my husband and mine. It's pretty amazing to reflect back, like even in the short 10 to 15 years, How far we've come along, frankly.

[00:05:55] Griffin Jones: So that was part of how you chose the state that you ended up bad. Well, one of where you got married in New Hampshire in 2009, but then to practice in 2014 at at RMAarmy and sorry, that was, that was , your fellowship was in, was in Massachusetts. Your fellowship was in Boston and then your, and then, so it was your first job after fellowship was in New Jersey.

[00:06:16] Dr. Daniel Kaser: Brand spanking new, like infertility fellow just finished and then signed on to join RMA of New Jersey and yeah, and moved to actually Philadelphia. At the time and the practices helping open up in Southern New Jersey for RMA was like just across the Delaware river. So I would commute across, across state line and would go to work each day. But I was at at RMAarmy New Jersey for a few years and really help them develop LGBTQ kind of care.

[00:06:48] Griffin Jones: Why that practice though, Dan? So I'm following why you ended up in New Jersey, your interest in. REI in particularly this application where I started pretty early, you said you were starting to figure it out and med school that this directly impacts my community directly impacts me. And a lot of people don't come to that realization so early or at least not, for their subspecialty often they don't even, , come to their specialty until a little bit later.

And you notice it pretty early on. So, but what about the practice continued to follow that line for you? 

[00:07:28] Dr. Daniel Kaser: For me a couple opportunities that at RMA that attracted me there, frankly one was to help open a new IVF center for them and in south Jersey. And so a dear friend and partner Jason Franasiakfor Phasiac and I helped establish an open it a new center there for, for RMA to kind of anchor the south which was an amazing opportunity directly out of fellowship to be involved in everything from architectural plans to kind of operation.

And management of the decisions, large decisions down to the various tiny finishes and things. So that was a compelling reason right out of fellowship to come to RMA. And then secondly, I had the opportunity to, based on my interests egg donation and teargas to help lead their third-party program.

And so truly, a year out of fellowship I had had taken on for, for the practice of $25 or so the director of the third party role, which feel fortunate of that opportunity. And frankly had really great mentorship there in New Jersey to have helped me kind of establish myself in that as not only an interest of mine, but something that, I have expertise in and, and I'm excited to be able to offer patients, frankly.

So it was the was really a great, great opportunity at the right time. 

[00:08:52] Griffin Jones: What was it like building out the LGBTQ plus practice area, part of the third party program, practice area. So you've got a LGBTQ plus focus as a part of third party. What was involved in building that out? 

[00:09:09] Dr. Daniel Kaser: Yeah, it's in looking back at it, there was already, , program there.

And frankly, since the practice it opened in 1999 that been, had opened doors and had been inclusive to patients of any sexual orientation or identity. But I think it was more systematically and kind of comprehensively thinking about this as like a sector of care that is growing and that we need to have a more COVID program. And so, the care is in terms of what actually is being done at donation and surrogacy. It's not unique to gay men, for example. But some the messaging and, and frankly some of the like content online and how you interact with patients and what patients expect it is unique.

And so, in working with the third party team there it was helping to grow, a few aspects of, of the program specifically like advocacy an online presence. For, LGBTQ care both, on websites and social media, and then also frankly, getting involved in research this area as well.

So it, I think went from, offering these services to try to kind of put together a program, frankly, where it is not only taking care of patients, but also the broader community.

So at RMA help helping to establish really a comprehensive program for LGBTQ patients. We took efforts to develop the advocacy role, frankly, as physicians and healthcare professionals, thinking about this community and what we could potentially offer.

And at the time, surrogacy was illegal and in New York. And so basically like serve to the lobby mostly through like newspaper editorials and writing letters to senators and, and and representatives in New York. Just frankly, how important this type of care is for the community.

We also took on some research projects specifically to evaluate, best practices for for LGBTQ patients, one we published in, a major journal looking at the role of one versus two inseminations for single women and also lesbian couples using donors from, to try to establish whether, a single IUI was, was sufficient or if a second IUI, added benefit and did not in that study did not seem to.

And then we also published the experience that RMA has with over some 10 to 12 years of several hundred men who had gone through the egg donation and surrogacy program to become fathers really just talking about access to care. And it was a web-based survey that we distributed to former patients and current patients who, who were undergoing this treatment to ask them questions in terms of how are they paying for this treatment is insurance covering it?

Are they having to travel from out of state to be able to access this? And similarly published this and, we're surprised to learn, frankly that something like 40 or 45% of men who we were seeing like didn't have the opportunity to do the type of treatment that we were offering them within their own state.

Some of that reflects just the kind of broad catchment area that a practice like RMI has and that, people come from out of, out of town, out of state, but, but not all in that, some, a good number of programs either. Don't have a lot of experience in, this type of care or choose not to develop it.

And we were hoping to, by thinking about this as a more cohesive program hoping to help establish it as, a destination spot for gay men and women, frankly, where they would feel welcome, they would see team members that were in the community. And would frankly feel celebrated undergo in this type of treatment?

I think, in working in some, I now I'm in practicing in San Francisco, still with RMA. But in San Francisco, I would say roughly one out of five individuals or couples that I see is, is LGBTQ or a single and doing this with donor gametes. So it's definitely, I have somewhat of a biased perspective, but it's a growing part of fertility care.

And these, patients have choice frankly, and where they go and in meeting with them, I think what's unique about, about the consult that you do is that they're not typically, haven't struggled with years of, of infertility or miscarriage or pregnancy loss. And two are coming from that very initial consult in addition a different spot in their life.

And some of them may never have, have thought that they were going to have kids and the decision to, to like set up that initial appointment is a large one in that it's like, they're there consciously, like for the first time undergoing the steps that are needed to, to have a child and to start their family , the, the pregnancy rates that we can offer through, through this type of treatment, they're really the best that you can do.

And fertility, in terms of in particular egg donation and surrogacy. So it's never, never a guarantee. It's never a hundred percent certain, but they're overall very excellent clinical outcomes. And I think the tone of the consult from day one is it's frankly helping them celebrate that choice that they're, that they're starting their family and helping to reinforce that choice, that they're making a good decision and, and educate them about, about the process, not only the fertility treatment, but, connecting with other, other couples or individuals who have who've done this and have young families.

[00:15:27] Griffin Jones: By doing that you're validating that they came to the right place to, and you mentioned earlier that, that they have a choice in where they go. And it does seem to, to me that a handful of doctors or a handful of practices see far more than the proportional representation of same-sex couples and many see far fewer perhaps because many see far fewer.

And it reminds me of, of someone called me a couple of years ago, and they really wanted to target same-sex couples and particularly same-sex male couples. And they were just, even before we even got to needs or shit, well, how much will it cost? How much it will cost and as a lot, because you haven't done anything yet.

And all you're doing right now is coming and saying, I just want more of these dollar signs coming into my practice. Meanwhile, there are a numb, there are some people in the, in the country, doctors and practices that have really been. Practice areas for, for that. So can you talk about, I mean, now that you're in the bay area I'm guessing maybe a lot of those folks are, are local, but maybe I'm wrong on how far people traveling for.

[00:16:44] Dr. Daniel Kaser: Yeah, it's an interesting question. I would say most are within California currently, and particularly in the Bbay Aarea, there's a large community. And it's becoming more and more common for men to, to have not only one kid, but come back for a second child. I would say right now it's probably 10% of the of the patients that I see, like specifically for egg donation and surrogacy are from outside of this state.

But just in the last six to 12 months, I think the word is getting out. I'm starting to see more and more international couples that are, looking for care as well. So I think that's frankly, perspective in like being a gay man with a child through egg donation and surrogacy.

It's something that I'm passionate about in helping other, other couples go, go through the process. And I think offer some additional kind of context to the, the decisions that have to be made along the way too so. 

[00:17:47] Griffin Jones: You have the rapport that the personal rapport, because of your own experience, you have the advocacy that you've been a part of the he talked about the messaging as a part of that, but you alluded to some, some systems that at one point earlier in the conversation, what were some of the systems that you had to update to better serve LGBTQ+ patients?

[00:18:10] Dr. Daniel Kaser: Yeah, it's really fascinating to like, sit and think about this about like, and some of it happened organically and other was, more thought out the fertility care, frankly, really grew in the nineties and early two thousands.

And a lot of the practices that, that formed at that time, w either weren't offering this treatment or weren't offering this treatment well. And so a lot of the systems were, were built, frankly, ,around straight couples only. And, had some inherent biases kind of baked into them, not intentionally in my opinion, but truly just reflective of the care that, the type of patient that they were caring for and, and what a family looked like in the nineties 

and in early two thousands.

[00:19:00] Griffin Jones: What are some examples?

[00:19:02] Dr. Daniel Kaser: Yeah. 

 One is just representation, frankly, online in terms of the content that's on, on websites. There was a survey that was done in, in 2017 that was published in fertility and sterility that looked at this and they looked at all start reporting members at the time and they truly just looked at their websites to determine whether or not they had content for LGBT patients are not, and it was actually just 53% of the time that the 300 plus start clinics had had any content whatsoever for gay couples. I think if you did that study now, if I had to guess it'd probably be more like 75 or 80% but it's definitely still not a hundred percent.

So just truly, even like having content on your website and like appropriate information, there is one example, another example is intake, frankly like intake forms and how patients and their partners report their medical history and, and basic things like sexual orientation and gender identity, a lot of.

A lot of practices ,are still there intake forms are gendered and assume that they have assume you have a partner. And so, , one of the structural things that that I helped do kind of early on in helping establish this program is just frankly, the look with a critical eye at the forms that, that patients sign and submit on establishing like a new patient.

Everything from the non-discrimination policy, making sure that it had, LGBTQ kind of identifiers in there to frankly collecting sexual orientation at the initial call and preferred pronouns and intake forms that, that we started with were interestingly, they were kind of custom-made for different kind of types of treatment.

Then, so far as like a heterosexual couple, there is a separate form for a transgender patient. There is a separate form for a lesbian couple. And we thought at the time it felt like the right thing to do as you could really tailor the questions that you're asking to that particular type of patient.

And then through frankly, patient feedback just inexperience in working with different couples. It actually, and not surprisingly, it became clear. Like these separate forms, don't always capture the broad range of experiences people have and the types of patients and frankly ways that they can do treatment.

So it was hard to kind of put, put people into a box of a form. And so we actually like just generalized one form and went back to one, an intake form, but made it very, very inclusive and so.

[00:21:57] Griffin Jones: So that's interesting to me because the nature of sort of everything is to become more fragmented, right? More, more specific, more specialized start with three TV channels than we have with cable and have a hundred.

And then we'd go to the internet and we have infinite. And so one would have thought, okay, we're starting from, we're back at the time where it was just partnered male-female couples. And then we started to serve maybe gay women. Then we started serve gay men. And now transgender couples and others.

And so I would have made the assumption that you've you further segment and, your experience taught you otherwise. 

[00:22:31] Dr. Daniel Kaser: Yeah. And that, I mean, that is exactly right. And that, that was our initial consideration as well. It just didn't seem to work as well as a single form did and just making sure the language and the form had had space and had range to cater to the different patients that we care for another example of this is in terms of like looking at kind of structural things about a program is the medical record and how, these episodes are documented by the clinical staff and whether or not you can, query whether, sex, sexual orientation or partner status in the medical record.

So you can, do research. You can't change anything or can't look at whether an effect is, or an intervention is improving anything. If you're not measuring that. So true. The first, like one of the first things is like we have to collect sexual orientation and for everyone coming through the door and like you, interestingly, it's like the first time that this was being counted, that like gay gay men and women were being counted in the practice.

And it's crazy to think about it, but it wasn't until the 20, 20 census actually in the United States, that sexual orientation for the first time was like included in the 20, 20 census. So like also, now being counted in the us census as well. And with the hope to like that, that can, by measuring it, you can, address gaps and, figure out where resources are needed, if you can do research projects.

So in any event, the medical record just is truly being able to. To count how many consults you're doing of this type is important. And then also other things like, allowing nicknaming to happen, where you can assign like a nickname for a patient that's in particularly important for like our trans community in that a lot of trans men and women don't like identify with their birth name.

And they actually referred to it as their dead name, like their name assigned at birth. And so they go by like a nickname. And so whether or not your EMR can capture and can assign like nicknames as the preferred names. We looked at consent forms to make sure that consent forms weren't gendered and assumed a partner status. So I think that it's looking with a critical eye at every kind of interaction that a patient and partner might have from the initial call to the consult, with the physician day-to-day interactions with our front desk staff even working with financial counselors and, and the, the program and having options for that are inclusive for financing this frankly there, there are some, some outside organizations that allow you to take out quite a, a large sum that, that have money that you can finance at a low interest rate.

So just frankly, like having information available about how to make this a feasible thing to undertake, I think is important. And, being in network with some non traditional payers is not the right word, but the, the major payers, like historically in fertility care are the major players outside of, fertility as well the Blues and Aetna and so on. But, some of these groups and I have no relationship with any of them, but Progeny and Kara and Maybin, some of these payers are, are, are doing frankly really revolutionary things for LGBTQ care in that they offer egg donation and surrogacy benefits, but they don't, they are not concern whatsoever about a patient's sexual orientation. So one of the biggest ironies in my career as like a fertility doctor start like going to set out to start, my family is at the time I was in practice, in New Jersey, a mandated state, and truly had really amazing fertility benefits through a major payer that covered everything in IVF, they cover the egg donation and even covered like a reimbursement for, for surrogacy. But the irony is that based on, who I was married to I actually didn't have access to any of those benefits in a mandated state, as a fertility doctor with really, really comprehensive plan. And that doesn't sit with you well, when, when you experienced something like that firsthand and fortunately, there are other ways to make that journey feasible.

But in looking and looking back at it, there are a lot of a lot of insurance companies, frankly, in my opinion, are discriminatory. I'm still against, against our community in, in helping establish families. And they have a very I think outdated definition of infertility and like who, who has access to this type of care and that they're defining sexual intercourse between a man and a woman not leading to conception after six or 12 months.

So, for one in 20 individuals in the U S now that's not a reality. And so even if you don't choose to use it benefits. I think it's important to like be included to have the option as you're paying into that. So these other payers like progeny and so on just truly by not defining who can access their benefits has really revolutionized the number of patients that we're seeing and also like how many people are frankly interested in, in, in starting, starting their family. It's not surprising to me when you like lower barriers to certain things, more people come and more the interest is broader than maybe initially expected. So think over the next 10 to 15 years, we're going to see a tremendous Increase in the number of gay patients that we're caring for. And I think really important to like, make ensure that your, your practice is, is up to date and contemporary with, this type of consolidate and this type of care.

[00:28:52] Griffin Jones: I want to ask you about where you see the trend going, because you're managing third-party and LGBTQ plus patients are a part of that.

And you said one, you said about one out of five patients is LGBTQ plus. And so do you see within that, you mentioned you think it's going to grow in the next 15 years? Are we already starting to see some doctors that it is there enough demand now that in a large city, that one doctor could say, well, of course I see anybody but given their case load they're, they only see gay male patients. One, are we already starting to see that too? Is that what you're talking about when you're seeing that growth in the next decade and a half? 

[00:29:31] Dr. Daniel Kaser: It's a really interesting question. And I honestly feel like based on my own clinical volume, I could do that. I almost could do that now. My partners would probably kill me.

[00:29:41] Griffin Jones: But why would your partner stay? 

[00:29:43] Dr. Daniel Kaser: Know just based on the clinical volume. But I think frankly at some point I'll probably be there  markley and dearest RMA Connecticut is really become a mentor of mine over the years. And he's honestly the only one of the only docs that I know that like exclusively cares for men going, going through the process.

I dunno if I would necessarily like, be that specific in like all egg donation, all surrogacy. I frankly like the whole breadth of doing donor inseminations for single women and lesbian women and frankly being helping members of this community get to the point of being a parent.

So I do think, in particular, I do know some other recent graduates that are gay and are open about, about their life experiences, I think have interest in this as well. And even some current fellows that may as well too. So I genuinely think that this is like, it's a very specific segment.

But I think if done well, you can, you can this can be like a reason people seek out your practice and it's a way to differentiate your 

[00:31:00] Griffin Jones: practice, frankly, Dr. LeondiresLee and has been on the show as well. We'll link to that episode. It's probably a two year old episode. Now we'll link to it in the show notes.

Why did you move out to the bay area? 

[00:31:12] Dr. Daniel Kaser: I moved to San Francisco to help RMA of Northern California open and kind of establish their third-party program and help develop kind of LGBTQ care here as well. I also am like joined two really great friends as partners and it was another great opportunity at the right time.

[00:31:34] Griffin Jones: So it is RMA of the Bay Areabarrier. Is that also part of Eva RMA or it's different because I know that there, like you mentioned, Mmark LeondiresLandis of RMA of Connecticut who had, who have just rebranded. So their Allume fertility now, like that's not part of VRMA neither, neither is RMA of New York. And then, there was RMA of Texas and they're not an RMAIronman anymore.

And then there's others that are, they're all straight up part of the same VRMAEVR. I'm a company. Nobody seems to know the answer to that. So where do you guys fall in that spectrum? 

[00:32:02] Dr. Daniel Kaser: It's a great question. We are a part of the RMA network or UV RMA in northern California.

[00:32:09] Griffin Jones: Okay. So your true blue EVRMAavian army.

So you were staying within the same company. You knew where you were moving from the east coast to the west coast. They were starting, they were building that practice out there and there was the opportunity to, to, to relocate You mentioned there any other major, I mean, New Jersey, hadn't had a mandate.

You mentioned though that their mandate wasn't completely inclusive. , and now you're in the Bbay Area were there other major differences between the two states that are worth mentioning?

[00:32:39] Dr. Daniel Kaser: That's interesting. I would say in California particularly in the Bbay Aarea, there's more directed, like known egg and sperm donation then out east, at least currently, or where in New Jersey, I was in practice in that Individuals and couples come with like a particular person in mind that they're wanting to donate.

And I think it frankly speaks to like how fluid certain kind of families are and like what family looks like, and, and the 21st century in that, I have frankly friends that, other gay men who have acted as a sperm donor for like a single woman, for example. And so in, in California, I see more and more of those kind of creative ways that you can start your family.

And I think it's really rewarding to not only help like screen and educate the sperm or egg donor and what they're doing and, and link them up with, reproductive psychologists and counselors who help them navigate frankly, what this means for their life and what type of relationship they want to have with the child.

But it's I think more and more, at least in this community Important for for patients to know their donor. So I think the trend is probably moving away from kind of anonymous or not known egg donation and sperm donation people, frankly, we talk at every consult when, when using donor gametes that, it's not truly anonymous.

And in particular with, Facebook and 23 and me Google image search, if you wanted to find your donor like an anonymous donor you're absolutely would be able to do so, or like often.

[00:34:31] Griffin Jones: So for that reason, we don't say non miss anymore, but are you saying not just not just for that reason.

Can we not say anonymous? Are you also saying that we're moving away from undisclosed? That it's, are we moving back toward, are we moving towards disclosed for that reason? 

[00:34:47] Dr. Daniel Kaser: Yeah. I mean, I see more and more people choosing like the open ID or identity release, where you can like learn about the sperm donor at age 18.

If the child wants to, or doing truly like known or directed sperm or egg donation, just say the child has an option to, to like meet their part of their origin story and couples navigate that differently. The couple or the child or number want to explore that. And others, others are really curious about that when my husband and I went, went through egg donation, we we wanted to like have an egg donor that we knew.

And we did so through the, through the practice and met her, not only really, for two reasons, one was to protect that option for future contact. But secondly was frankly just wanting to thank her for truly like what a life-changing thing that she has done through egg donation and every donor that.

I tell him or her that in that I genuinely thank them for what they're doing for that couple. And I think on a busy day, it's like easy to, to lose that perspective. And it's easy to think about the egg donor who had 30 eggs retrieved and what a great response she had, but in particular, like, going home to a child from an egg donor and like playing ball in the backyard or holding your son reading them a book, like recognizing that, like the only reason that, that you're in that space is through like some altruistic act that, that someone else went through.

I think it gives you like a tremendous amount of perspective and just, you feel so grateful that like what, what these men and women are doing. And so I like caring for the donors themselves too. So it's a part of that is like, educating them not only about their own fertility and like about their hormones and their body but also just, letting them know what an important task that's what an important endeavor that they're undertaking and to thank them.

[00:37:00] Griffin Jones: Well, we've made some creative about that.

And that makes me think of some more and that topic could be, could be its own show topic. I'm going to let you conclude the way you want to conclude about the future of third party, but the feature of serving LGBTQ plus patients. But before I let you conclude, however you want, I'm going to, I want to drag you into a fight, Dan, and you can choose to pick a side in the fight.

You could choose to break up the fight but I am dragging you in here. And this is the fight, which is recently I've had. And everybody's allowed on the show. We've had 130 plus I think you're going to be episode something 130. Plus everybody is allowed on this show, small practices, large practices, people that are coming from venture capital and private equity people that say they're going to stay independent forever.

Everybody's allowed on recently. I've had a couple of groups on one in particular that has a model of expanding or their value prop, whether they serve it or not is another question. But their value prop is to expand care by having RBIS oversee. OB GYN or maybe PA isn't it NPS.

And and so this, this has started some stuff. I think they're going to come back on the show stomach of at least one of the doctors that I had at Christmas has volunteered to come on and, and hash this out. And and I was at PCRs and people were bringing it up to me. And so I wonder where you sit on this and I want to say, I did get emails from REIs as well.

That said, I love this idea. Can I talk to these people? And there are already REIs that are already doing this model on, on their own. But the objection of course, was Dan that, that can, somebody just can just a, a generalist, OB GYN. Who's never sat through any part of fellowship training, do what I do.

And where are they being transferred? Are they being shipped down someplace? How many cases is the REI overseeing, how closely are they overseeing them? Are they doing it remotely? Are they right there in the office? And so that you're board certified REI Indeed and you're someone that sees the bottleneck of care and that only a fraction of the people that need treatment in this country are getting it.

Where do you opine on a solution like this? 

[00:39:17] Dr. Daniel Kaser: Yeah, this is I think an important point and I think we'll, we'll, we'll see this settle out sometime in the next five to 10 years, in my opinion. And I completely agree that you, you speak, we talk to different REI's and you'll get different opinions of this. I, my personal take on this is truly I could write. Be the doctor that I am care for the number of patients that I do on a regular basis care for the type of patients that I do without, advanced practitioners like nurse practitioners and, and physician assistants, for example our practice in Northern California is relatively small in terms of physicians.

I'm one of three docs here. And then we have three advanced practitioners. So two NPS and one PA, and the advanced practitioners help with monitoring with ultrasound, with insemination to sailing sonograms with notably donor screening with gestational carrier screening. And they're absolutely superb in what they do and they bring such a additional kind of level of care to patients.

And, I think are a member of the team, like are absolutely critical to our team functioning as it does. So I think they frankly allow me to be a better doctor. And I honestly go to them sometimes asking their opinion of things. If I have a catheter placement for a saline sonogram, that's tricky and my partner is out that day.

Absolutely. I'm gonna ask for, one of the nurse practitioners to come and see if she can, she can pass it. So I have no, no pride there whatsoever. And we've two of the three advanced practitioners that, that are on staff with us right now. We've trained like from the beginning and you can, absolutely have them kind of augment your practice and some of them started.

[00:41:08] Griffin Jones: Did you manage 10 of them or 20 of them remotely. And could you, or if they're OB-GYNs and if they're doing the retrievals and the transfers, are you still on board then? 

[00:41:19] Dr. Daniel Kaser: Yeah, it's a great question. Whether like to, what, what point of, of care that, that someone outside of an REI doc would, would be involved?

I personally think like embryo transfers, shift. There's so much an embryo transfer is like the culmination of someone's treatment. And so much goes into that in terms of IVF lab, the costs, the emotions, the physical aspect of IVF. I personally don't think, many patients would, would be on board with having a non position or like, not even there.

Doctor not do the embryo transfer. 

[00:41:53] Griffin Jones: So I think that was, they might have, it's a question of age of eight grand all in including meds and everything else versus 20 grand all in name. They might Dan.

[00:42:02] Dr. Daniel Kaser: It, no, I mean, if, particularly if you tie int cost, I mean, you have a compelling point that like maybe they don't care as much as they might expect, but there's always going to be patients that do.

And I think we're at a unique kind of crossroads in the, in the specialty, in that like we're seeing increasing volume. We have like a certain number of trainees 40 plus that, are finished fellowship each year. And as you, in your own words, there's a bottleneck in clinical care.

And so. I see a couple of things happen to in frankly and I see some, some practices going the route that are cost cutting and ways to offer more affordable fertility care and like improve access to care with, in the hope of, driving up numbers and driving up frankly the number of patients that you can help.

And then I see other practices taking a different stance and this is like a kind of a premium product that we're offering. And, people are willing to pay like, Dollar for higher value for better outcomes for more personalized attention. So, I mean, I honestly think there's probably space for both in, in fertility care because not every patient is looking for the same thing.

I think like to pigeonhole, like all fertility patients into wanting like the lower cost option. I think it's, doesn't capture the breadth of patients that we see. I think there's room for kind of both those models. 

[00:43:35] Griffin Jones: So, and this should, there should be a debate really, should it not in one of the little breakout rooms either it should be in the big room because I think it would shake up some salt.

You could be the moderator. And I think that it's a good topic and standing room only. 

[00:43:53] Dr. Daniel Kaser: Yeah, I agree. I mean, I think it's an important, important thing. And I think if we don't actively like discuss it, I think there is some tension there.

[00:44:02] Griffin Jones: But I don't want, I don't want somebody like you arguing either side, Dan you're too in the middle.

I want people on hard on each side arguing it. And then I want somebody like you to moderate, to moderate it, Switzerland. Okay. You can be, you can be Switzerland. I'm Switzerland on the show, but I have zero clinical knowledge, which is why I always, whenever I bring somebody on, like I say, this is what I'm seeing in the marketplace.

You all decide if it's clinically valid. If it's the best standard of care or even acceptable standard of care, I'm not qualified to give first aid to a paper cut. I was a D student and then I went and got a communications degree from Oswego state, which is why I own a marketing firm.

So I let people talk and then I let the clinicians deciphers out. But I think that would be a great for you to debate. And before I let you conclude, I want to say, if anyone is listening, I would love to do an episode from somebody from a bog to talk about what it would actually, what would actually be involved in going from.

Fellowship programs to a hundred I've kind of asked guests that Al a carte on the show. I would love to talk to somebody from bog who, who could really spend a podcast episode going through what that would be like to go from 40 episodes to a hundred. So if anybody's listening, that's an invitation or a request to the email me, if you can hook that up, Dr. Kaser I'm going to let you conclude with how you want to either about serving LGBTQ plus patients, or just about third-party program in general the audiences, yours what are you paying attention to? What do you want to see for the field? How would you like to conclude?

[00:45:38] Dr. Daniel Kaser: Thanks for having, for having me on the show. I'm a fan and like, it's really an amazing opportunity for me to talk to you about this. I would leave you with, for listeners who, whether you're a physician or a nurse or an embryologist or in marketing at a practice, really any role is just to look inward for a moment in terms of how you're caring for the gay community.

And, I had given a talk at the most recent PCRs this year about quote unquote LGBTQ friendly practice. And how do you build a  friendly practice. I had just finished at the, when I was putting together the slide deck I had just finished “How to be An Anti-racist” by Ibram X. Kendi.

The fantastic book that like talks about just structural racism and just how things embedded in the system whether conscious or not can impact people's lives in a material way. And in reading that book, I started in preparing my slides for that talk. I started to think about are we really talking about LGBTQ friendly care?

Is that really what our patients deserve? And I came to the conclusion, ultimately that we should really be doing better than LGBTQ friendly. Well, what my community is looking for and fertility care is to go to like a welcoming practice or practice that celebrates their family story.

And frankly, one that's not homophobic. And so, like the thesis of that presentation was not talking about how to like, run an LGBTQ friendly practice, but rather how to run an anti homophobic practice. And, I think semantics are important. And I think if you haven't read that book, it's absolutely worth the read how to be an anti-racist.

And I think it gave me some of the tools to fight. Like critically about my own practice and ways to improve it and would just encourage listeners to do the same and consider how we can rise to the unique challenge of caring for men and women who want nothing more when they're sitting across from to become a parent. 

[00:47:58] Griffin Jones: Well Dr. Dan Kaser thank you for coming on the show. I have another book. Woke Racism which is a rebuttal by John McWhorter, but check out both books. And Dan had the last word. So read Dr. Kaser's book recommendation first Dr. Dan Kaser. Thank you so much for coming on Inside Reproductive Health.

Thanks Griffin.

130: Does First Class Service Win in the End? with Terry Malanda

On this episode of Inside Reproductive Health, Griffin Jones chats with Terry Malanda about patients’ freedom of choice. Terry, the owner of Mandell’s Clinical Pharmacy, believes that customer service is the North Star for long-term company growth. With all the consolidation happening, Griffin and Terry explore the current state of how consumers make their pharmacy decision and future trends on what will impact that decision.

Listen to the full episode to hear:

The debate on freedom of choice for patients to choose a pharmacy Why pharmacies can and should be providing additional services to patients, including benefits coverage and discount programs How consolidation of fertility clinics is reducing the choice that patients have when it comes to pharmacies and other services Why some pharmacies outsource their compounding, and what that means The virtuous cycle vs. the vicious cycle of customer service

Terry’s Info:
Website: https://www.mymandellspharmacy.com/meet-the-staff/

Twitter: ​​https://twitter.com/mandellsrx

Linkedin: https://www.linkedin.com/in/terry-malanda-09ab9528/

Inside Reproductive Health is sponsored by EngagedMD. For technology that educates your patients with true informed consent, visit engagedmd.com/IRH for 25% off your implementation fee.

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[00:00:51] Griffin Jones: Freedom to choose in Inside Reproductive Health. I like stirring the pot, but that one we'll save for another day, but you're probably already writing to Engage MD to cancel my sponsorship depending on wherever you're coming from in this sphere, Terry Malanda's probably like what the heck?  Griffin had to introduce her podcast episode like that?

I did. I couldn't resist. We're talking about the freedom of choice for patients to choose what pharmacy they want to use among other things. We're talking about the freedom of choice for patients to choose what they want to choose and what that's like in the fertility space, with all the consolidation happening, reducing that choice that patients have when it comes to pharmacies and other services.

Pharmacies can and should be providing additional services to patients. At least according to my guests, including finding out benefits, coverage, and finding out discount programs, some pharmacies outsource their compounding. And we talk about the implications for that. And we talk about the virtuous cycle versus the vicious cycle of customer service.

My guest for today is Terry Melanda, co-owner of Mandell's Pharmacy. And we talk about all of this and more from a woman in business who has been here before. We've seen a lot of women as principals of their companies, and I was very happy to have her on the show, and I hope you get something out of the conversation.

And I look forward to your feedback. I know you'll give it to me, whether I want to hear it or not. Enjoy this episode of Inside Reproductive Health with Terry Malanda. Mrs. Malanda, Terry, welcome to Inside Reproductive Health. 

[00:02:37] Terry Malanda: Thank you, Griffin. It's my pleasure to be here. It's great to see you. 

[00:02:40] Griffin Jones: It's about time to have you on because you know that you're a good speaker and if people know you, they know that sometimes you're a little shy about, but I just thought of a couple years ago, Mandell’s sponsored a virtual event that we did.

It was a patient facing event. It was a virtual fertility conference. This was actually pre-COVID and, and, and you recorded your presentation, and my employees were like, she's so good. And I was like, she is so good. Somebody needs to tell her that. 

[00:03:08] Terry Malanda: Well, well thank you. I appreciate the compliment.

I know I spoke at a public event, and I remember I brought a speech that I have prewritten, and then once I was there I just after hearing stories and patient stories, I just ripped up my speech and, and I winged it. So, thank you. I appreciate that compliment. 

[00:03:25] Griffin Jones: Sometimes it's just like, you know, it's like having the seatbelt there, even though you're not gonna need it.

Right. And then you end up having a good conversation or a good talk or in the case of when I do, presentation, as soon as I see somebody's eyes, then I can go into a different headspace. And I become a better talker. At least I do from my vantage point who, who knows if the audience agrees or not.

[00:03:48] Terry Malanda: I think it's from the heart. I think when you speak from the heart, it's, it's a lot more genuine and I think that's what you do on your podcast. That's why we enjoy listening to them. 

[00:03:56] Griffin Jones: Well, and that's why I wanted to have, when I wanted to just get kind of a State of the Union of what's going on in pharmacy, that you were the person that I thought of just to, to speak of, of what's going on.

We haven't had too many discussions on this show about pharmacy, and, because partly, Terry, because I don't know what the doctors, like, really should know and, and versus like, what's what, what might just be boring or incidental information to them. So can you kind of just give us like if you, we were at PCRS and a doctor was sitting down with you, and just said, like, Terry, like what's going on across the pharmacy field right now? How would you start with a really open-ended question like that?

[00:04:40] Terry Malanda: I think I would probably first back up a little bit and let them know how important it is to choose the right pharmacy, or for the patient to choose the right pharmacy. We're only a small part of the infertility picture. Obviously,  the doctors have a lot more interaction than the nurses and, and a lot more to say and, and decide, but dealing with at the right pharmacy who truly understands what the patient is going through understands the role of a pharmacy, and how to best help a patient navigate through that portion of the journey, I think is really important.

So I think I'll probably stop start there. Then if you're asking about current events, I'd probably address the fact that there is so much consolidation happening and how it's changing it. Pharmacy's always changing. Always. The landscape is always changing, but right now there is a lot of consolidation.

There are a lot of companies that are buying out pharmacies and creating different models. Not that they're better or worse, they're just different. And I probably, you know, have a good discussion about that with a doctor, but I think the important thing when choosing a pharmacy is to make sure that the staff is very dedicated, that they're passionate about what they do.

And that the patient is gonna be in really good hands, pay a really good price, and have the support necessary, both educationally and frankly, emotionally from a pharmacy. That's gonna understand that. I always say that we and my family, we went through two things. We went through cancer. 

Thank God my husband survived the bone marrow transplant in 2005, but we went through infertility in the 1990s, and they are both catastrophic illnesses. And, I think that no one who hasn't experienced it and dealt with it for a while, really understands just how disruptive infertility is in the life of the patient and, and the couple and the relationship and the finances.

And I believe that having a pharmacy who even just understands all of that is very important. And in order to do that, it can't, it has to come from the top and you have to have training the, the appropriate training and, you know, it has to come from the heart. I just believe that everything has to come from the heart and you're dealing with real people with real situations and a couple who are really struggling often just to get through this, and sometimes repeat treatments, et cetera. So, to go back to a pharmacy, I think it's just important for doctors to really know their pharmacy, understand what a pharmacy is, and how much a pharmacy can do for them. Our tagline is sort of, we make it easy for you, so we try to help as much as we can the clinic and the patient.

So it's really teamwork that happens when a patient uses us. So I don't know that all doctors know that I think that many do and many appreciate it, but I'm not sure that all of 'em understand it. 

[00:07:26] Griffin Jones: Well, maybe we take the angle down. What can a pharmacy do for them? Because if I'm playing devil's advocate, Terry and I'm the CEO of a, a, a large network that has just consolidated a number of clinics, or even if I'm not, even if I own a practice and I'm the single provider and I'm thinking, well, like, choosing the right pharmacy's, like, yeah, I understand that some people may have more heart than others and, and some people might be able to do a little bit customer service, but at the end of the day, it's, it's the drug- getting the drugs to the people. And I wanna just get it to them for as cheap as possible, because the drug companies’ charging them a lot.

I'm charging them a fair amount, and I wanna just get them as cheap as possible. And so I'm gonna refer to whoever and, or they can choose whatever pharmacy they want or, or will use one that this private equity group has told us is gonna be cheaper across the scale, whatever it is. So you know, I'm coming with a commodity. 

What is it that the pharmacies could actually be doing for them?. 

[00:08:26] Terry Malanda: Well, I'll tell you what we do. And I know that we actually do the things that we say we do. For example, as soon as the patient starts out with us, we give 'em a full education on what to expect next. We also always, if the patient has any medications in their order, that qualify for discount programs, we encourage them to, we tell them we educate them on the discount programs and encourage them to apply because you never know the discount programs we happen to be, if we're always the number one pharmacy. For the discount program that our company runs with Toronto with compassionate care. I think there's been a consolidation of several pharmacies, and now we're kind of neck to neck, but I know that that is a result of all the education that we give patients.

We apply coupons. We're always looking out for the best price. We always offer the best price. And when we offer a price, we don't increase one thing to decrease the other. We have never done that. We're very proud of the fact that we're very transparent. With our pricing and kind of stay away from what I call gimmick.

Because I think the fertility patient has plenty to deal with and to have to try and figure out the very complex world of pharmacy pricing. We assist the nurses tremendously. So the other thing we say to clinics is with us, let's fax it and forget it. So whether the prescription comes in electronically or via fax, we are gonna handle it from there.

We do absolutely everything from A to Z. And if the patient, for example, in the insurance company, if it's mandatory, a situation where the patient has to use their own pharmacy that is with their insurance company. And we determined that the coverage is there. We handle the entire transaction and we notify the clinic. So, this way the patient always knows what's going on and the clinic always knows what's going on. We also try to work and really customize services for the clinic. So if you're a new clinic with our facility, we would ask things like, how do you prefer to be contacted?

You prefer email. Do you prefer to leave a phone call, get the right contact people. And we really do a lot of work up front to make sure that we're maximizing their time, not interrupting as much as we can and making it easier for the staff at the doctor's office. ‘Cause nurses work very hard, and doctor’s time is very limited.

We are fully aware of that. So we have an entire prior authorization department. We make sure the patients get their orders. And if the patient, if there's some sort of a delay, we make sure that we're contacting the doctor's office and contacting the patient and they, and trying to figure out a dose for that day.

And we're very highly successful at that. That usually happens like if in a very bad storm, I mean, I'm sure every office knows that sometimes when the weather gets in the way you, you're not able the patient is not able to get it, but we also, that's another thing we do. We watch the weather across the country.

And so when we see bad weather coming, we anticipate that we have a way to contact all the patients and get their order out either before the storm or after. So we do a lot of behind the scenes work and that takes a lot of service. It takes a lot of employees and, quite frankly, it's expensive.

But as far as providing those services. If you compare our pricing to other pharmacies who may not provide exactly the same degree of service, we're usually, if we don't beat 'em, we're right in that ballpark. So, I just believe that service matters to a patient. I was a patient, my husband and I got into infertility because we couldn't conceive, we had trouble.

I was 28 when I started trying, and I got pregnant when I was 34. So you know, it was, I dealt, we didn't do infertility back then. And I dealt with a different pharmacy, and I just was not very happy with the level of service, being a pharmacist, myself. I knew what you can do for patients. And so we just decided to specialize in infertility.

I mean, we were very lucky. We did a frozen embryo and that worked, and then our, daughters, they're 20 months apart. And she came without any help, which is amazing. So we have two miracle children who are grown now. And we absolutely are passionate, and we love doing what we do, and we love the feedback we get as far as how much we help the patient, and frankly how much we help the clinics.

And I'd love for you to interview some of the doctors that use us and, and ask them that question, because I'm pretty sure that they would vouch for everything I'm saying. 

[00:12:43] Griffin Jones: Well, I know that if I interviewed different pharmacy owners, though, that they would say the same thing. So give me a couple of tangible examples of what practice owners should be looking out for, like, the level, like the specific service that makes a difference either in the care that the patient is receiving, or that is reducing staff burden. Because I don't know if Duane Read is still in business, but if they are, and I'm the CEO, let's pretend they are.

And I'm the CEO of Duane Read, and decide, we're gonna launch a specialty pharmacy infertility that my executives are saying the same thing. And I'm saying the same thing about the quality of service. And we got the best quality of service. And so what are the actual, like, what are as tangible as you can get?

What are those things that, that make the difference for patients and staff?

[00:13:34] Terry Malanda: Well, to be honest, any pharmacy, and I said this to doctors when I visit them and I'm trying to get them to prefer patients, any pharmacy. You're absolutely right at the beginning, you, you have a box of medication, you put a label on it and you, and you either ship it or get it ready for the patient’s pick up.

Right. Apparently, on the outside, pharmacy should be very simple, but it's all of the services that I've detailed. And it's not just saying that you do it, but actually performing the service and actually getting involved in solving the problems and the issues and the little idiosyncrasies that come along with, if the patients enduring their cycle.

For example, one of the things that we do that I'm, I don't know, you know, I'm sure maybe other people do, but I don't know. We take a complete history and we actually preface that to patients by saying that this is the only thing that we're filling for you. So we need to take, we're gonna ask more questions than your typical neighborhood pharmacy, because typically when you go to a neighborhood pharmacy, They wanna know your name, your address, your allergies.What's required by the board. 

We go a lot further than that. We take a complete history of medications that they're on, and we also take a complete medical history. And we had had patients who have had conditions where they really shouldn't get a cycle, and, but they forgot to tell their doctor. And we have one particular patient, this was probably the best story we've had about six or seven, but, well, the best one was, we had a patient who had, had an estrogen-independent cancer. And when the pharmacist reviewed her initial information, she reached out to the patient and said, did you discuss this with the doctor? And she said, well, if she wasn't sure if she had discussed it, she had, if she had been specific about the type of cancer she had, so she actually had to call her clinic back.

It was, it was a long issue. So what ended up happening is about a year and a half later, she called and spoke to one of our pharmacists, the one who had called her, and she called and said to, she called, thanking her for saving her life, because what happened was she delayed treatment while she was getting all of her treatment.

And her cancer came back without having started any treatment. So she had a three year old who was a naturally conceived child. And she said to our pharmacist that she shudders to think that, had she started treatment, she would've thought it was a treatment that caused her cancer to come back.

So we got involved in a clinical pharmacy. We do get involved on a clinical level as it pertains to medications. And also as it pertains to medical conditions And I think really a better answer to your question is that, you know, this, I hope this doesn't sound selfish, but it's what we hear from clinics.

A lot of people say they're gonna do what, what certain services, but then it isn't provided. For example, there are patients who have coverage. We call it hidden coverage because there are some medications that are not specific to IVF, and we can run those through insurance, and we'll take the extra step of doing a prior authorization with the assistance of the physician's office.

And oftentimes that can save patients hundreds of dollars, but typically what we hear, and the reason we get referrals, is that sometimes those patients, if there's no infertility coverage, they're just cashed out. The benefit is not investigated. We have a team of four people who do just investigations for insurance.

So, I think it's a matter of providing the service that you say that you're going to provide. And our staff does that, and they do it really well. So, I'm very proud of our staff. Honestly, the training comes from the top, but it's there carrying out of providing the services that constantly give us great reviews.

And, and I think it's important for the doctor's office to be proud to recommend the pharmacy. And it's a reflection on them. So, we put a great deal of pride and dedication into our work, because we know that, at the end of the day, we're representing them as well. If we, you know, we're representing the judgment of that doctor's office.

And we take that extremely seriously. 

[00:17:38] Griffin Jones: So, that you're, you're kind of getting to my next question, which is, is it enough for the doctors to care? Because I believe that the patients care because they say they do, there's yours, and a handful of others, that have really good reviews.

And you can, you can see what patients are saying, the reason why, part of the reason why you're on this show and, and I would allow a couple other people in your space to, to be in your seat right now- but not everybody- but, and part of the reason why it's you is not just because I know I've known you and Eddie for years, and I know that you're awesome.

People, I've never been a patient. So I don't know about that, but I do know how to read what patients are saying. It's overwhelmingly positive. And so I believe that, okay, it's enough for patients to care, is all of that enough for physicians to care, Terry? 

[00:18:26] Terry Malanda: Absolutely. Because I think that. Doctors truly care about their patients.

I don't know if they understand just how important it is to recommend a good pharmacy, but I do believe that doctors wanna do the best for their patients. I mean, I come from a family, I'm the black sheep. I'm the pharmacist, you know, half my family are all doctors and I, I see it for myself. I mean, I can tell you my sister's a gastroenterologist.

I can't tell you how many times over my lifetime that she's, being a doctor, we've been at Thanksgiving dinner, and she gets a call. She has to leave and go to the hospital cause someone is bleeding and you know, it's not, I'll be there in an hour. It's medicine. It is an extremely dedicated career. I mean, I don't know if the general public truly has an appreciation of just how hard people have to work to become a doctor, how hard they have to study. And I do believe that doctors care very, very deeply about their patients. I just, I don't know that. And, and I believe that many of them do completely understand the difference that the right pharmacy can make. However, I just don't know if all doctors know that.

So I appreciate the opportunity, obviously, to speak to you, because you're asking really great questions. And if a doctor recommends a pharmacy and the assumption by the patient is that they're gonna be well-treated and well taken care of, and that they're not gonna run into a gimmick, or they're call is not gonna be unanswered, et cetera.

So we think about it. This is getting your medications, is, like, is like the -what do you call the pre- what do you call, like a movie?

[00:20:03] Griffin Jones: The trailer? It's the trailer to the movie. 

[00:20:05] Terry Malanda: Getting medication is almost like a trailer to what's about to happen, because a lot of times, you're preparing sort of, but getting your medication, that experience is almost a trailer of things to come.

And one of the things that we also focus on is the psychological aspect of pharmacy. So we try to soften the blow and we educate our patients. You're gonna get a box, it's got a lot of things in it. However, you're not alone, you're gonna use one thing at the same time. I'm sorry. One thing at a time, you're going to be guided by your nurse.

Any questions you can call the pharmacy and that, that sticker shock of, of just opening up a box and seeing a whole bunch of needles is quite scary. And we started to do something about that when Eddie, my husband who's really in-tune with so many things, it's unbelievable. He was looking on YouTube and he started to, he found videos of people opening their boxes and looking at everything that was in it, and the look of shock and horror on their face, and years ago, we started to do that where we, we prepared the patient for the opening of the box there, they can call the pharmacy, and we can go over all their medication with them.

That's offered. And we also include things in the package to, to just so the first thing they see is beautiful and inspirational. And I, and, and we, our objective is to make people smile a little bit and look forward to the treatment as a positive thing. Not ever give false hope, because I don't think anyone in this field ever does that, but certainly just start this journey, best foot forward, and do everything that you can do in your power to increase your success. And by that, I mean we try to prepare people to be prepared, to be a good patient, a compliant patient. Because I know that, years ago, we used to get a lot of patients who would call and say, I forgot what dose my nurse told me to get tonight. Now, a lot of things are electronic now, so that has reduced, but years ago, when everything was just paper and you got a phone call before three o'clock, or before four o'clock, people would forget to write them down.

And we started preparing people for that. This is what you can expect when your nurse calls. Have pen and paper ready, write it down so you don't forget. Look ahead. The next few days, look at your medications and anticipate your needs, make sure that you have what you have, a huge one is to have the trigger, the trigger shot.

In my opinion, my humble opinion, is the most important injection in the whole, in the whole course of treatments, because anything else, if a patient makes an error and under-doses or overdoses, you could probably the, the reproductive endocrinologist can fix the problem. You, either, you can work with that.

You do bloodwork and you can work to correct that error. But if you don't have your trigger shot, when at the moment and time that the doctor needs you to inject, that's a big problem. So that's another thing we honestly, we don't have that problem because we educate people to, even if you're paying cash, your trigger shot is your insurance policy that you did not just throw away the last 10 days of your life- treatment.

And we educate patients on that. And we do it in a way where they understand what the importance of it is, and they always purchase their trigger shot along with their medication. Because it's that important. And it's knowing all the nuances of infertility and the things that can happen, or the things that you can prevent, and the amount of education that we try to instill in our patients and in writing, and also verbally that matter.

[00:23:30] Griffin Jones: So, now physicians are trying to think, okay, there's, there's a difference between pharmacies. I guess I've been hearing this from my nurses, or from my staff, and, okay, I'm starting to see that. Maybe it isn't just ‘send this piece of paper out, have the meds come back’ and that there's more to it.

You talked about consolidation and some things being different because of consolidation on the clinic side, it makes me think of something my dad says “the more things change, the more they stay the same”. And sometimes I think like, oh, that's just a ridiculous saying that my dad says, but I can kind of see what that means when I'm thinking of clinics, like, more things change, the more they stay the same.

So what is in the last couple years, just at a high level, what's different in the pharmacy world, and what's the same with consolidation happening. 

[00:24:15] Terry Malanda: I think the only big difference I see as a pharmacy and consolidation is when clinics will lock in with just one pharmacy or two pharmacies.

And I think that that's kind of the insurance model, and anyone who's ever had to use mandatory insurance, it works great for many people, but then there be, you know, we're in America, we should have competition. It's not a one size fits all. And what I like to see is, you know, obviously we never go, shouldn't say never, but it's difficult to go back to the old days.

But I think patients should have the freedom of choice to compare and go to whatever pharmacy they choose. And a lot of times just by calling around for a price call they get a feel for who they wanna deal with. And I think that's, that's, one of the things that has changed in the pharmacy world a lot is the consolidation and then picking one, you know, one horse in the race.

Well, what if the patient doesn't have a good experience? How does that reflect on the, on the, clinic? So, I would, I always say, I'll compete with anybody. I'll put up my staff against any staff. And I would like to see an open market of just having a variety of pharmacies to choose from, and let us all compete.

But when, when people compete, the consumers win, and that's always been the case. I honestly, I don't think I can think of anywhere where, any instance where that's not the case. And as far as you probably shop a lot. So some people like Macy's more, some people like TJ Maxx, some people like Bloomingdale’s, and sometimes you need to go to different places to find out what you like best, but having the freedom to experience.

[00:25:59] Griffin Jones: I'm all Barney’s all the way, Terry.

[00:26:01] Terry Malanda: Are you? 

[00:26:03] Griffin Jones: No, not quite, but I like fooling people sometimes. 

[00:26:07] Terry Malanda: Well, I just took my son to buy some suits, I should have spoken to you, ‘cause I haven't had to buy a suit for my son in years, but he's in law school, so he needs suits now. So yeah, it's, I think that there's been a very big change in the consolidation now.

The interesting thing is going to be, to figure out what wins in the end. I'm gonna, I'm betting my horse on, I'm betting on the horse of service. I'm betting on service. I think that at the end of the day, patients are gonna want to be treated really well during such an emotional time, during a difficult time.

I mean, women are so strong. They really are. It's unbelievable to me that, I mean, I was a patient myself, and I was proud of the way I handled it. We're jacked up on hormones during this, and to be able to go through your everyday life and keep your calm, and be kind to others while you're jacked up on hormones, is not easy at all.

But I think that we're so focused on the goal of getting pregnant, that whatever they tell us to do, we're going to do it. And it takes a large amount of strength to be able to, you know, go through this treatment. And then, as a couple, I know that it puts a lot of stress on a marriage, or on a relationship, because it's all-consuming when you're going through it.

I think a lot of women have the same experience I did when I was trying to get pregnant, and it took us four-and-a half-years to get pregnant. When I was trying to get pregnant,  all I would see, wherever I went was pregnant women and babies. That's all I saw. It's kind of like, I always compare it to when you're about to buy a car, and if you're gonna buy a car and you decide that you want, I don't know, like blue Volkswagen, right.

And you, you're on, you're on the highway, that's all you see or you see, you know, that you're so hyper-focused on one thing, and what your chore is of finding one that that's what happened to me, at least. And I know I've, I've spoken to, I couldn't count how many women I've spoken to going through this, and they have the same experience when you first start out.

It's not as grueling, but once you’ve had a few, if you are lucky enough to get pregnant right away, that's fantastic. But if you've had more than one failure, it begins to really dawn on you this may not happen and I know that would. 

[00:28:25] Griffin Jones: And we're definitely starting to see, see this, this ability to choose service go away and that people might want.

So, because I'm going through all of this, I wanna be able to choose someone that's really easy to work with. That really adds value to the education that I need going through this. But I can't choose because this is the pharmacy that I have to use. And I'm thinking a lot of doctors are probably listening and saying, that's not my fault, Terry.

 I would, you know, I refer to a number of different pharmacies, but if they use this insurance company or if they use this employer benefits broker you know, unless there's a shortage somewhere else, whatever it might be, they have to use this pharmacy so where is like the strain on choice starting to come from?

Is it coming more from, from clinics being consolidated or is it more from a decrease in cash pay in the marketplace? 

[00:29:13] Terry Malanda: It's definitely coming more from the consolidation, from what we've seen now. There are also plans, as you mentioned, that are selecting just one or two pharmacies to deal within a network.

And I mean, we're in talks with all those companies. And I really feel like eventually will be allowed in because, as they grow, they'll have more needs for more pharmacies, and more, you know, treat more people and service more people. But I see it a lot in the patients who are still paying out of pocket, and they're being referred to a pharmacy now.

We don't have any exclusive deals at all. I can tell you that any office that recommends us recommends us because they like to work with us. But, we don't have any exclusive deals with anyone. I've never even asked for one. Maybe I should, maybe I should start asking for exclusive deals because our service isn't gonna go down.

But, we definitely have gained the trust over the years. I've been in infertility for about 28 years now, strictly pretty much all infertility. We started doing strictly infertility. About 20 years ago, we do nothing else. That's all we do, even our compounding services, all we do is compound sterile and non sterile for fertility patients.

We've actually turned down hormone replacement requests. And not that there's anything wrong with hormone replacement, but we wanna keep our focus on the fertility patient. And the more you order things down, the more difficult it is to offer the kind of service that we do. 

[00:30:38] Griffin Jones: I wanna talk about that compounding, but you kind of like you, well, you tickled something in my brain that, I mean, you said you haven't approached anybody about it, exclusive deal.

And I'm thinking, well, why not? Like what there's, you know, six big networks. And then, you know, if you broke them up into a couple groups, there's a few, like really large groups in the country. And then you add Canada and there's one or two more in there. And, and so I think like, well, why not?

Why not broker a deal with one of them or approach one of them, you have the services look at how we can make this part of your end to end excellent patient care. Why have you not gone that route yet? 

[00:31:17] Terry Malanda: Oh, like I said, I might have to start because sometimes, if you can't beat 'em, you have to join them.

Right. But you've known me for a long time, I think for years. And Eddie and I have beliefs and we truly try to run our business with those beliefs. And, one of those beliefs is that we truly believe that the patients should have recommendations and then go find the better one or what they, where they feel more comfortable.

And to be honest, we have grown consistently year after year after. And it hasn't been by forcing anyone. Do we make every patient a hundred percent happy all the time? No, but I would say we're 99.99999%. No, no kidding. No exaggeration. And we're very proud of the fact that we've grown organically.

We've grown through recommendations and from good service providing the best service. If the market continues to change to a point where we're gonna have to, you know, bid to be the only pharmacy, we might have to do that. But so far we have not approached any company. We have gone to every company and been allowed to be one of the choices in the network.

And that's what we're working on. We wanna be one of the choices once. We're one of the choices in the network. We want patients to pick us. We don't, it's hard. I don't even know how they do it. It must be hard if you're forced to use one doctor or one pharmacy, or, you know, to be forced to do anything is not something that.

I would prefer to be a part of, so I'll leave that door open because obviously the market keeps changing to a point where we start to not grow organically. Then we may have to change our business model, but I'd rather stay the course and hopefully make others understand that people need to have freedom of where they go for their medical services, whether it be pharmacy or a physician or anything else, I'd much rather.

Stay the course. And I'm not gonna, we're not gonna change the world, but IVF is not that big of a market. So I kind of hope to stick to our guns for as long as we possibly can. And try to affect the positive change. That's gonna be positive for the patients and positive for the clinics to be able to, we have doctors, we have doctors who used this for years and now their clinic has consolidated and they can no longer send to us.

They're not happy about that. You know, so I'm proud of the fact that they're not happy about that. I'd love to have their referrals back, but the market is small enough, yet big enough, where we can make up the difference for any losses. And like I said, we've grown year after year and it's all been organically.

We're gonna try to keep that up for as long as we can. And we listen, if we get, if we do get a negative review, We definitely act upon that. We find out what happened. We investigate. And sometimes the negative review is, you know, 

[00:34:10] Griffin Jones: Sometimes there's nothing you can do about it. And sometimes, sometimes there is like what I'd say, and, and for the doctors listening, because they especially get sensitive to negative reviews.

[00:34:20] Terry's talking about the importance of the trigger shot here, and how that is like an insurance program for patients in and of itself. It's so tied into the outcomes of success. It's so tied into what they've invested already, and these are the things that Engaged MD helps with. Engaged MD's model helps with pretreatment education so that your patients know this stuff cold. It's not: they have to cram it all in the office, and they're like a deer in headlights. They're consuming this information at their leisure. They can do it on repeat and they get true informed consent along the way they check in with the module, making sure that they understand.

So by the time that you are talking to them or that your care team is talking to them, you are answering the questions that are really specific to them, making sure that they're able to comply with the protocol the whole way through Engaged MD helps with this because there's otherwise too much at stake for your patients.

And it's costing your staff too much to have to go through it over and over again. When Engaged MD provides true informed consent and pre-treatment education go to engaged md.com/irh. You'll get 25% off your implementation fee. If you mentioned that you heard it on Inside Reproductive Health, or that you heard it from Griffin Jones, go to engagemd.com/irh.

So you can put your patients and staff in a much better position and have much better educated patients so that they don't lose out on things that they could have known. Had they received the information at the right time, in the right way, engagedmd.com/irh.

 [00:36:03] Sometimes there's nothing you can do about it. And sometimes, sometimes there is like what I'd say, and, and for the doctors listening, because they especially get sensitive to negative reviews.

It's, you're looking for the patterns over time and it takes a really thick skin. But it's the right balance of, of humility, but not kowtowing to what everybody says. It's, you have to have the thick enough skin to be able to take in all of the feedback, knowing that not all of it is valuable or true or PC to, to distill down to the patterns, what are true.

And it's hard to do. And so I'd say like, if you, you know, one negative view, don't sweat on it, but when you do have when, and, but that's the benefit of quantity in feedback that if you do have thousands of customers and you can get hundreds of responses and, you know, two dozen aren't the best.

Well, then you look for the patterns between those two dozen, and, and so that's something that you do if you've given us a snapshot of, kind of the trend that's happening with consolidation. What about with compounding? How is this all affecting the way pharmacies compound or is it?

[00:37:18] Terry Malanda: Oh absolutely. Let me just go back to the review thing for a second. Sometimes our negative review is when a patient wants something that's simply illegal to do and, and we can't do it. So once in a while we, we sell drugs, right. So we cannot just say yes to everything, but we once in a while, someone is unhappy about some and we definitely start, you know, look into that.

[00:37:38] Griffin Jones: Oh, that's just a little, not, not from Mandell’s, that's coming right from Grif for all the enterprising street drug dealers out there. There you go. There's a lead gen source for you. You just go to the negative reviews of pharmacies when they're complaining about something that the pharmacy can't sell them to you.

There's your market. Just kidding. Legal disclaimer. Just kidding. Okay. 

[00:37:58] Terry Malanda: Disclaimer. 

I get it though you asked me about compounding, how that's changed. I'll go back a little bit historically, most pharmaceutical companies, if not every single pharmaceutical company that has ever existed, they started out as compounders.

If you ever saw the movie, It's A Wonderful Life. And you remember the scene with the pharmacist, you know, the scene right? Where he?

[00:38:19] Griffin Jones: Mr. Goer, I was trying to think of the pharmacist name. The pharmacist's name is Mr. Goer. 

[00:38:24] Terry Malanda: Thank you. I should know that, but I don't. But George realized that he had put a poison in the capsules.

And so you remember that scene, that's how all pharmacies started out compounders. So compounding is an ancient art, as long as medications have been made or are tried. And there was a time when there were no pharmaceutical companies, then some of them had formulas. Some compounders had formulas that they found to be very effective and would be very popular.

And so they started to market the mass market and that was the birth of pharmaceutical companies. So. Compounding fits special needs for people. Not all of the compounds that are made in for the treatment of infertility are of it. None of 'em are available in the market on the market. So sometimes there are certain doctors who have protocols that require us to make special products that are going to help the patient get pregnant, create the right environment for the uterus and for, you know, increase the efficacy of the other medications and allow the patient to get pregnant.

How that's changed is that years ago, I'm gonna say this is about eight or 10 years ago. A lot of changes happened. There was a huge tragedy that happened in New England and that kind of woke everyone up as far as government agencies. And so the government started to change a lot of the rules and regulations and got much stricter.

With compounding practices and put in a lot of new and not easy to achieve regulations on books that combat pounding pharmacies have to follow. So a lot of people ran away from that. We built a bigger lab. That was our response was let's build a bigger lab, USP800, USP797, USP795 compliance and get several pharmacists certified to do sterile compounding.

I think that a lot of, I don't think I know that a lot of the pharmacies are outsourcing compounds and not necessarily a bad idea to do that, except that some patients. Don't like that because they have to now rely on two pharmacies to get what they need. And sometimes it's more than that.

Sometimes there are products that maybe a pharmacy doesn't sell. And so they have, they end up using two to three pharmacies. And what that's one of the reasons that some of the nurses, some of clinics are happy that we, we have everything that they need. Like, whatever it is that you need, we're gonna be able to make it, whether it's compound or any other medication.

We have everything that the patient is going to need to cycle. And you don't have to worry about. Tracking to see if a pharmacy sent it and then the pharmacy be sent it that they both get there at the same time and is every ready for the patient to start. So that's how it's changed compounding for us.

It's actually been a bit, a huge benefit for us to be able to compound. 

[00:41:12] Griffin Jones: This might be my ignorance. Hopefully somebody else is wondering it so that I seem less dumb. But you mentioned in the Mr. Goer era. So back then, he probably would've been, not even called a pharmacist, right? Probably would've been called a druggist back in those days.

A druggist and you said from the druggist was born the pharmacist and born the pharmaceutical manufacturers making do actually making the drug. So why did compounding stay on the pharmacy stream and not become the responsibility or the role of the pharmaceutical manufacturer?

So I wouldn't you know, if we're lacking compounds, then why doesn't the doctor called the drug maker and say, this is what needs to be made?

[00:41:54] Terry Malanda: Because there are so many, for example, I'll just say market dose Lupron, I'll use a really good example for this and thank you. That's a great question by the way.

Cause it begs the question of why aren't manufacturers making it so micro-dose, leuprolide the typical three strengths that we make it in, which are the most popular 40 per 0.2 50 per 0.2 and 40 per 0.1. So it's 40 micrograms of lide in 0.1 or 0.2, right? However, there are different doctors through the country that they want 10 micrograms or they want 20 micrograms so there are variations. So anyone can make that, but in the world of compounding, when you make a sterile compound, you can only assign it. And I won't get too technical, but it either nine days or 14 days, depending on the circumstances under which they were made. And by that, I mean, for example, if I'm making a compound, the first two needle punctures, make it a 14 day compound.

If I have to put a third needle in the valve that that becomes a nine day compound. So with the variety of different strengths it difficult for a pharmaceutical company to make one or two strengths in enough quantities to make it profitable for them basically. So it's a very small part of a very large selection of medications that are used in fertility. And then for example, in progesterone when we give dating to compounds for example, our pharmacy, we had to do studies on the three main strengths that we picked. We did studies, their extensive studies are very expensive to do and very detailed.

And then if you can prove to the FDA that your compound is good in that container for that amount of time and that it's a sterile product and this really holds until your expiration that you can give it dating. So work with the dating. We have some studies that show things are good for six months, but we only give it four months or three months just because we wanna be conservative with our dating.

 For example, another reason to, with compounds that one of the biggest things that we compound is progesterone and oil, and that is commercially available. It's available in Sesame oil and it's fairly inexpensive, so it works great, but it's a small cross sensitivity, but there is a cross sensitivity between Sesame, which is a tree nut and any other nuts.

So peanuts, cashew, anything. So any patient who has any kind of an allergyto a nut, you don't wanna risk using Sesame oil, maybe nothing happens, but there's like a 5% chance that you could have a reaction. And obviously in someone who's trying to achieve a pregnancy, you don't wanna have this complicated by some sort of severe allergic reaction.

So there are doctors that use strictly But there's one or two or three clinics in the country that I know of that strictly use the compounded formula because there's so many people now with allergies and nut allergies, and sometimes they don't even know they have it. So they prefer to use something that isn't gonna give 'em welts or swelling and itching, et cetera, because the, the reactions can be mild or they can be severe.

It typically they're mild, but if the patient gets pregnant and has to stay on progesterone for six weeks, it's pretty hard to inject six weeks into an area that's very sensitive and swollen and itchy it's torture. So the, a doctors who opt for that if they see that the patient's having a reaction to Sesame.

[00:45:16] Griffin Jones: So you can have challenges with compounding things like PIO or in general, it's certainly an inconvenience to the patient. If they have to go to more than one pharmacy for, to get a compounded script. But you said that the other pharmacies will reach out or refer out to other pharmacies or they'll outsource the compounding.

Do they ever outsource to you? 

[00:45:38] Terry Malanda: Well, we get a lot of we do get patients that the prescriptions are transferred to us. And that's, you know, that we do help patients. We're not gonna turn patients out. So we do help patients. That being said, we have to be careful with that because as I said, we really focus on service, Griffin, and we had it happen a few years ago, where all of a sudden when all this happened, They started to refer to us.

And so what happened was we increased our batches that we make, we increased the size, but then along time, the holidays, and so less people cycled, we ended up throwing half the batches away. It was very unpredictable, extremely unpredictable. So we try to focus on servicing the clinics that are using them.

We bundle price and we try to make sure that we don't run out of product that has dating. ‘Cause obviously part of the reason to use our pharmacy is that the inject the medications have dating. They have good dating. So if you get the later week or they get the later month you, you could still use the product.

And ‘cause it was specifically made to be used within a certain amount of time. 

[00:46:44] Griffin Jones: So you may have answered my next question then, which was gonna be, is the market big enough to warrant a compounding only pharmacy that is outsourced by other pharmacies? And so if the trend for other pharmacies is to move away from compounding to outsource more or is there a, is the market big enough for one person or one pharmacy just to say, okay, we're the compounding pharmacy, all of you can outsource your compounding to us, and then we'll do it for you.

 So this is now specialized enough that you don't have to have it in houses, does the market bear that. 

[00:47:17] Terry Malanda: I think it could, but compounding is so highly regulated that I think that it would, if you consolidate that portion of it, I think prices would really skyrocket because testing a batch is very expensive training your pharmacist, it's ongoing training or all the time that's expensive.

So it would be difficult, is it big enough.

I would wanna be that pharmacy put it that way. I think you would have a lot of waste because IVF happens in weight. So we usually try to compound based on sales, which is kind of what you're supposed to do, but when the market slows down, you'd end up throwing a whole lot of product away.

And if, you know, we could take losses that are small, but if you had to take a loss that big, that's a good question. Maybe if you had more dating for more products, there could be a pharmacy that did compounding. We're certainly set up to do that, but like I said, we focus on taking care of mostly our patients and we don't turn patients down, but we do focus on taking care of our patients.

So for example if we're in danger of running out of my 90 day or 60 day compounds, or I may have to make them a 14 day compound, we don't turn 'em away, but they don't get the benefit of having the extra dating. That's kind of the problem that you would run into. But a lot of, I think that's some of the pharmacies that compounding now have dating on progesterone.

Not all, some other pharmacies do have dating on their compounding, but some of the pharmacies that are doing the outsourcing, they don't necessarily have a lot of dating. So that's another factor that you have to consider. I guess that's what we've heard from patients. 

[00:48:57] Griffin Jones: Then what do you see as what's going to change or you think are gonna be the biggest changes in the field in the next five years?

So I, particularly as it relates to the pharmacy space, but the IVF field in general, what are you paying in the next three, five years? 

[00:49:12] Terry Malanda: Definitely consolidation. That's I think that's a big factor that's happening. There's a famous well famous to, I mean, everyone in the audience will know what I'm talking about.

But years ago there was a partnership that was made between a pharmaceutical company and a particular pharmacy and that in the end it didn't work out. So I think that this is going to be for a while and then services are going to change and come back. One thing that I have to mention that I think is a big change and I think a good one.

I love men, no offense to men. Yeah. I have a son. I have a husband. I love men. But it's nice. 

[00:49:47] Griffin Jones: Right?

[00:49:48] Terry Malanda: No, no, it's just nice to see so many women prominent in the field of, in for two have pioneered. A tremendous amount of the research and they've come up with the treatments, et cetera, et cetera. But it's really nice to see that a lot of women are getting really involved in the business and, and coming up with business models and service companies.

Some of them have done very well. Some of them haven't done well, but it's just nice to see that in a field that it's so much dependent on, on the, the person carrying the baby, it's really important to, to see that women are getting into that field. And I kind of like it, I think I'm the only female pharmacy owner, I think, in the country.

I'm not sure, but I'm pretty sure, I don't know any other female, there were was one, but she had retired and it just. 

[00:50:36] Griffin Jones: You're ahead of your time. 

[00:50:38] Terry Malanda: Huh? 

[00:50:38] Griffin Jones: You're ahead of your time. I don't think we'll be saying that 20 years from now. I hope we're not. 

[00:50:42] Terry Malanda: No. 

[00:50:43] Griffin Jones: But I don't think we will be. 

[00:50:44] Terry Malanda: Absolutely not. And that's one way where I I'm seeing the market changing a lot.

And it's nice, you know, when men and women can come together and really set a goal and, and really go after it, I think I'm a believer that men and women think differently and that it's a great, it's great. When you put that together, you come up with excellent ideas. Because we believe that different people see the world in a different way, and it's great when you have different and not necessarily just men and women, just different people, putting their heads together and coming up with innovation and coming up with great thoughts.

And you can't put yourself in everyone's shoes, you know, it's you could say it, but it's hard to put yourself in everyone's shoes. And that's one thing I always try to do because I'm, I'm now older. I'm not in the age group of women who are going through infertility. And I always wanna listen to the, to the people who are in that age group.

And that's what we try to do as far, or is like marketing. And how are people thinking about different things, new trends, you know, it's just changing. The popular nation is changing. Our society has changed. And I think it's great to see innovation catching up with those changes and with all those changes and with all that individuality.

And I think that service is key to kind of, to tie it all up and a knot. 

[00:51:57] Griffin Jones: So that I wanna talk about it a little bit. So I'm with you on the first two trends, more consolidation, at least for a while, more females in the executive and founder roles, I see that and so for you, is coming back to service, is it a Renaissance of service?

Is that something that you really believe is going to happen, or is that wishful thinking? Because my answer might have been different than it was eight months ago. I wanna talk about that, but is it for you? Is it something you really believe we're gonna have a Renaissance of service or is it-you hope we'll have a Renaissance of service?

[00:52:26] Terry Malanda: Here's what I believe. When the service aspect goes away, things will fail, and then service will come back because that already happened with the example I mentioned earlier. So I believe that you know, we've always said we never wanna get so big that we lose the personal touch, and we mean that we really do mean that.

And I think that when things get so big and so controlled in a matter of, you know, where profit becomes the number one driving force and that's, that's the force, the service aspect falls apart. So I think it's wishful thinking that will happen. Does that answer your question? 

[00:53:07] Griffin Jones: A little bit, but I'm starting to see more evidence for your hope here in what's happened in the overall economy the last year and a half, since people have like, oh, like I'm not gonna work my restaurant job, or I'm not gonna work this service level job. Or, or even in client services in marketing agencies in 2021, there was a, for 40, the average understaffing of agencies was 40% in 2021. It was we're understaffed for 40% we were. And so was the national average and the quality in terms of like, delivery. We still delivered every, but of, like, just that extra service. Absolutely it's offered for us. And I'm admitting it to everybody here and, but also everywhere Terry, like I ordered a, you know, I ordered like a late night meal a few weeks ago and I ordered it at, at, you know, like 9:30 or something.

And, and then I go at, and I get there at 9:58, they close the tent and they're just closed up. And I'm like, I called ahead. I ordered, we’re closed-up. We're done. Or like, or all of the places that you called to make a reservation. It's just, nobody answers the phone or you make your order online.

And, and they say, okay, we'll deliver it next. You know, we'll deliver it on Tuesday and it's like a week later. And this is just across the board of, oh, really felt service suffer. 

[00:54:25] Terry Malanda: I'm absolutely with you. But I would say this and I'm probably giving away more information than I should, but I would say this, you have to make your employees care about what they're doing.

And you have to, if that your employees don't care, if they don't understand, if they don't get it, that person doesn't belong in your, whether it's a restaurant or it's a clothing store or it's a pharmacy, or it's a doctor's office. I think that if you're not able to inculcate the importance of what your, these patients are in the case of pharmacy, what these patients are undergoing, how important it is to them, how they're, you know, people are taking out loans to pay for this.

They've been saving for years to pay for this. And if you can't get people who have a good enough heart to, to get that, to really understand. That, then, your service will go down. We spend a lot of time doing that. It's the urgency, the importance, the care that they have to have. And I can tell you that we coach our employees.

We will talk to them if they just don't get it, or if they don't answer those, we've had employees, like, leave a five o'clock to five o'clock bell ring, and then there's a message on their machine that they never picked up. But luckily we have other employees who check every phone before they leave. So that's a taught behavior and you have to go through a lot of people before you get the right people.

In the case of restaurants, that's a tough one where him, because you know, that's a tough one, but in our case, I think it's not difficult to have people if you're lucky enough to find people who have a good heart, I don't think it's that difficult for them to understand just how important their position is.

And their role is in this patient's journey and in this patient, having everything that they need. And we really instill a sense of urgency in our staff. So that every patient who needs to be serviced is serviced every day. Have we ever faulted on that? Absolutely, once in a while, a fax doesn't get through or something, you know, technical, it's usually technology actually.

But, and have we had employees who didn't answer an email or did not answer yes, but then they're spoken to it. If they can't correct that behavior. You have to run a tight ship. I would say to answer that question, you have to run a very tight ship and it has to be very personal. 

[00:56:45] Griffin Jones: So you don't think it's as hard as restaurants in that sense, but I think it is Terry.

I think it, and part of the reason why you're feeling a little bit less in that sense is because you're always on top of it. And my hypothesis is that it's either a virtuous cycle or a vicious cycle. And for those that are in the vicious cycle, it takes a lot of discipline to get out.

And the virtuous cycle takes a lot of discipline to stay on it. But whether it's a restaurant or a client services firm or a pharmacy that I bet you, you know, if we were just starting out Terry and like we're recently qualified pharmacies recently qualified business people have good hearts, it would take us a, a, we would have a lot of pain in trying to build that team eventually.

We would do it because of who we are, but that's my point is that it, it is a constant investment to be able to, to do that. And, and now I'm really starting to pay attention to, like, even companies that are known for, renowned for their service are, have suffered. And I've been paying attention, like, who in this unprecedented labor market?

We’ve never seen anything. Like it is still able to offer quality service. Those are the people that I'm really paying attention to. 

[00:57:55] Terry Malanda: Yeah, no, I agree with you and not to change a topic, but COVID has affected this country in so many ways. And as far as the economy, I just don't understand a lot of things. I don't understand how people aren't going to work, but yet a lot of businesses are thriving and it's just, none of it makes sense right now.

So I agree with you. I think that's a little bit of what you're trying to say. Right? Am I wrong? 

[00:58:20] Griffin Jones: Yeah. I think, and then part of it is because it's like, well, I think part of the reason why people are doing well, it's like, yeah, I could go to another place to get that meal, but most people are in the same boat right now.

And so it's like part of the reason why they're doing well is, is just because this is happening to everybody. And so there are so few people that it, that really is reliable service every time right now. 

[00:58:43] Terry Malanda: I think the big differentiator is if you treat your employees, that you give them a job or you give them a career.

So we try really hard to give people careers at Mandell’s, if you can perform, if you're really good, are a great employee, and you can really provide the service that we, we always say our customer service, we want it up here. Everyone who's interviewed here is that. And once they're hired as well, we expect it to stay up there.

And I think that for some people just it's a paycheck and they're gonna go. But I think some people understand that if you're serious about your position there, you're gonna get ahead. You're gonna grow with the company and we have a lot of people who've been there for a very long time.

So you know, I don't know that and all work is honorable and no way do I mean this to be, but if you work at a restaurant, you can work at, at another restaurant, restaurants are driving and they're dying for help. So you could work anywhere you want. So there's a little bit of a power shift, I think as far as employers trying to get people to work for them trying so hard, we went through that.

When COVID hit the whole country shut down, I mean, all, you know infertility shut down all elective services shut down and they were shut down. Luckily things reopened for infertility. But it was terrible because when, when they shut down, I was in Mexico.

When we got the news, we were, we had just gotten on a vacation and we didn't hit outside of the hotel room for four days. And it was terrible. We were gonna have to lay people off and we'd never had to lay anyone off. So we were very careful and really looked at. Didn't try to see who we could keep et cetera, et cetera.

Turns out that outta 23 people, 21 of 'em laid themselves off. They didn't. They said I don't wanna come in. I'm afraid. So I really struggled with that and it turns out they laid themselves off in the end. So there was a lot of fear and there, you know everything has changed so much. There are so many industries now that have found out that they don't really need to have someone in the office.

They don't have to pay a lot of office rent, especially in big cities, like New York city, et cetera. So I know I'm totally off topic, but it's just a very complicated phenomenon that's happening now. There's so many different ways to look at it. And in some ways it dones a lot of good as far as rearranging the way that Americans work, but in other ways I still don't know why so many people are out of work.

And so many people are looking for people to work, you know, so I really can't, let's hope in the next few months, more people will join the workforce. 

[01:01:09] Griffin Jones: Yeah. And hopefully it isn't too ugly when the other shoe drops either. But we'll be ready if it does. Terry, how would you wanna conclude for our audience either about what you wanna see happen in the IVF space in the next years or what you feel that every practice owner should be cognitive of, of how they use a pharmacy.

[01:01:30] Terry Malanda: Oh okay. Thank you. I would like, if I had my wish, every physician would interview pharmacies, and, and then try give pharmacies a try. We had I won't mention her name, but we had a nurse here in New Jersey that would always give every pharmacy a try and then come back to us.

So go ahead and give other pharmacies a try sample though and see how they do. And then if you go with the, be the one that services your patients best, and I'm pretty, I'm very confident that we would win in that race. So that's why I'm putting it out there. And I would like doctors and nurses to understand that the pharmacy that they use plays a huge, huge role and in your everyday life with your patient and especially in the patient's life, I really think that we really help patients get through this journey as seamlessly as possible, at least our aspect of it, and do our best for them every day. That's our goal every day is to do our best for every single patient that we can. So that's about it. 

[01:02:32] Griffin Jones: Terry Malanda thank you so much for coming on inside reproductive health. 

[01:02:36] Terry Malanda: Thank you, Griffin. I appreciate the opportunity and I'll see you at PCRS.

[01:02:40] Griffin Jones: Looking forward to it. I'll be there.

129: The Biggest Shifts in Fertility Patient Demographics with Dr. Janet Bruno-Gaston

Technology is changing how we look at fertility and family planning. On this episode of Inside Reproductive Health, Dr. Janet Bruno-Gaston (Director of Fertility Preservation at Center of Reproductive Medicine, soon to become Shady Grove Fertility Houston) joined Griffin Jones to talk about how the latest technology in fertility preservation affects decisions of families today. 

Listen to the full episode to hear: 

• The current state of artificial intelligence for fertility doctors.

• How technology in fertility preservation is changing couples' family planning decision process and what that means for you. 

• Easy ways to increase referrals from physicians in your area.

• Griffin’s rant about the metaverse and how it could change the landscape of how you treat patients. 

Dr. Janet Bruno-Gaston:

Website: https://infertilitytexas.com/meet-the-team/

Linkedin: https://www.linkedin.com/in/janet-bruno-gaston-1bb6a014b/ 

Inside Reproductive Health is sponsored by EngagedMD. For technology that educates your patients with true informed consent, visit engagedmd.com/IRH for 25% off your implementation fee.

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Transcript

[00:00:00] Griffin Jones: This is just crazy old Griff, throwing out a fastball for everybody.

I was talking with a friend at the Association Reproductive Managers meeting last week and. She has a child in early teens and I said do you think so so's. generation will, do you think more than 50% of them will have children? She said no. And I said, I totally agree again, speculation.

[00:01:02] Griffin Jones: The future of fertility preservation, artificial intelligence, practice areas, the metaverse. These are some of the things that I talk about with Dr. Bruno-Gaston in my episode today. But before we get to that, a little shout out for Dr. Susan Davies from Chicago, sometimes I get really lovely messages from you all, and they don't always have to be out business. So sometimes. You can send me a personal note because you thought of me from hearing the podcast. And I love that. So shout out to Dr. Susan Davies for making my day one time and all the people at her practice, including but not limit to Aanal and Shannon and hope everyone there as well.

Okay. In today's episode with Dr. Janet Bruno-Gaston from the center of reproductive medicine, or by the time you are hearing this Shady Grove Houston. She is someone that has dedicated a practice area to fertility preservation. She did her medical school at Morehouse. She did residency at USC, did her fellowship while getting master clinical investigation at Baylor.

And she's presented at many conferences and written on number of topics, including non-invasive markers of gammetes and embryo viability, PCOS, a number of different things. But what we're talking about today is her practice area in fertility preservation. What the future of it is the technologies that will disrupt or increase it.

And what it's like for younger doctors to go on that kind of career track. So I hope you enjoy today's Inside Reproductive Health with Dr. Janet Bruno Gaston.

Dr. Bruno Gaston Janet, welcome to Inside Reproductive Health.

[00:02:44] Dr. Janet Bruno-Gaston: Thank you so much. I'm super excited to be here this afternoon.

[00:02:48] Griffin Jones: I'm excited to have you and to talk about fertility preservation. I'm interested in a few different areas. One, because I think it's gonna be the it is one of the fastest growing segments of our field.

I still think that that is going to increase. Maybe some people thought it was gonna grow a lot faster than it did. Maybe some people think it's done growing I still think it is going to be one of the, the fastest growing areas, but I wanna start with just, how did you decide it? This was a particular area of interest for your practice, because there are a lot of young docs listening or there's people at docs at groups that maybe they were a two doctor group now, but now they're at a 7, 10, 12 doctor group and there's areas for different people to carve out their little niche. And so how did you decide that this was something that you wanted to pursue?

[00:03:41] Dr. Janet Bruno-Gaston: Yeah, I think for me I'm a little biased by my training experience. I trained at Baylor college of medicine and got an opportunity to work with Dr. Woodard at MD Anderson. So we have a strong exposure, to fertility during our training. And for me it was a niche that didn't allow me to abandon kind of the basic reproductive physiology and the breadth of reproductive pathology that you would see practicing general REI, but added the complexity of cancer diagnosis and working around that.

So it was challenging. It was a very interesting patient population. They're extremely vulnerable and it's a very humbling position to be able to step in, in the midst of everything they're going through and talk about building a family and what future family planning looks like for them. So I really enjoyed that exposure.

During fellowship and went into private practice. And in my group ,there was no one really championing that cause. So it became a very smooth transition for me to help recruit patients, improve access to care and really Kate for more educational awareness about options for fertility preservation, because as you alluded to this field is continuing to grow.

The options are becoming unlimited and it is not only for medically in patients, but as obviously elective as well.

[00:05:14] Griffin Jones: So your interest was peaked by the medically indicated by oncofertility. And then at around this time was, was social egg freezing as they were calling it or elective fertility preservation.

Was that starting to blow up in the public sphere or was it already kind of being talked about on social media? How did your interest from the medically called foresight meet with that.

[00:05:39] Dr. Janet Bruno-Gaston: So I think I was just at the cus where we were starting to see fertility preservation and specifically oocyte cryo preservation being talked about in public platform.

So you'd see it on a good morning America, or a talk show in the afternoon. It was something that people started talking about. And I think with the shift in society of how people are building their career and thinking about family planning. It was just very intuitive that this, this was something that needed to follow that shift.

And while as an infertility specialist, I am not promoting an intentional delay in family planning, but what I am strong and passionate about is providing patients options. And each patient has a different family planning goal. They have a different outlook on where their life is going.

And so providing them options is really important for them to help navigate that process.

[00:06:40] Griffin Jones: So you're physically in Houston to Houston area, right? I am. And I remember in 2015, 2014, 2016, when egg freezing really started to. I wouldn't even say it really took off, but really started to get buzz in New York, LA San Fran was like, okay, it's here now in just a handful of years, it's gonna be in Atlanta, Dallas, Houston.

And then after that probably your Cleveland's Buffalo, Detroit, I could say that I'm from one of those areas. And so did that happen in that way? Did you see a big increase and then start to flatten off. Did you see a continuing maybe not a hockey stick, but an upward into the right curve?

What has growth been like or not been like since you've, you've been practicing in this area?

[00:07:28] Dr. Janet Bruno-Gaston: Yeah, I think that's interesting. I can't say if it's been growth from a geographical standpoint, but certainly what I am seeing is different iterations of fertility preservation. Right now I'll say there is a huge push or advocacy mission to extend fertility preservation to the trans community.

And even having discussions about that and what that looks like as people are performing gender reassignment, surgeries hormonal therapy. And I think as a REI we have to now embed ourself in that conversation because a lot of that is happening with Pediatricians or primary care physicians, depending on where they are in life when they decide to make that transition.

But I think an important part of that conversation and something that was missing from that dialogue is whether or not they want. Children or how they want to build a family. Because for a long time, I think the assumption was a part of making that transition was letting that goal go. And certainly fertility preservation does not require that.

And it provides very unique options for that particular patient population to consider family planning.

[00:08:40] Griffin Jones: So that's one demographic that is increasing in utilization of fertility preservation. I wonder if you're seeing it this way, where we think of fertility preservation is for those that want to extend their family building window and they it's like an extension of their plans.

And I wonder if as the generation's grown a more useful way of thinking about it is maybe not even an extension of plans, but an option for people to change their mind. Right. Like, I really wonder if the, if the birth rate just continues to decline and doesn't stop. So I think part of what we're seeing in REI right now, part of the reason why everyone is so busy is because the median age of childbirth has gone up.

Right. And so I wonder if, that's just, okay, it's gone up until it's gotten to the point where the trend just continues, that people don't want to have children, but fertility preservation is an opportunity to say well, but if you change your mind, do you think people are starting to think, do you think about it that way or do you think it's very much the extension of a plan?

[00:09:57] Dr. Janet Bruno-Gaston: I see both and I'm smiling because as you were describing that maybe I might change my mind. I mean, I've been across the room, had a patient say that to me. Hey, I don't even know if I want kids. This is something my job is covering and I hadn't thought about it before. And maybe I will in the future.

So that's why I'm here today. So certainly patients are starting to look at and think about their reproductive years and say, Hey, what do I want to accomplish here? And if family planning is not a part of that immediate goal. Certainly fertility preservation can be an option to say, Hey, I may be interested in this later on.

So yes, I do agree that there is a subset of patients that strictly want to not close the door on that option of building a family in the future.

[00:10:55] Griffin Jones: I wonder if it just like becomes what we do as a field. Like I really believe this is total speculation. I have no data to support. This is just crazy old Griff, throwing out a fastball for everybody.

I was talking with a friend at the association reproductive managers meeting last week and. She has a child in early teens and I said do you think so generation will, do you think more than 50% of them will have children? She said no. And I said, I totally agree again, speculation.

And I was like, well, what percentage do you think? And we're like, ah, I don't know, 25% again. No, no to data whatsoever, but it's seems to me that this is the direction that we're going in. And so we're what we offer part of. Of what you all offer as the clinicians in this field is the opportunity for someone to not lock that in.

[00:11:50] Dr. Janet Bruno-Gaston: Mm-hmm mm-hmm

Yeah. I mean, I completely agree. And while we don't have data to look at that long term regrets, things like that, those studies are just kind of gathering information because as you said REI in general is in its infancy still when you compare it to other disciplines of medicine and certainly fertility preservation is so we're still gathering data on what that looks like in terms of utilization regret in terms of what, or they did not, or did not did, or did not use fertility preservation.

I don't know if I think there will be a huge paradigm shift in terms of the decision to build families certainly finances and, and just the structure of our society have changed the way people look at the amount of children they want in their household. And when they decide to start their family but I do agree that having fertility preservation does change the sense of urgency particularly for women obviously in that they can and consider other things in life and when they start considering other things in life differently, I, I think.

There will be a shift in value system. I don't know how long that will take and if we're just seeing that evolve. But yeah, those are my thoughts.

[00:13:12] Griffin Jones: Well, I just think for all the people listening that have like preteens and teenagers, it's like, I doubt the ability. I doubt the ability of that cohort to be able to raise children.

It'd be nice to be wrong, but I really, but I they're gonna have the metaverse. I say that somewhat in tongue and cheek, but, but honestly, Janet, you say that kind of joking, I'm dead serious about the metaverse and we look at in this, I think the metaverse is at now. I'm really gonna go off on it too.

She's gonna be like, why did I go on this guy's podcast? I came to talk about fertility preservation and I got him down a rabbit hole of the metaverse. I think it's as possible of a paradigm shifter as genetic testing and CRISPR for childbirth that it could. So if the value prop behind CRISPR and genetic testing is.

Look at all of these awful diseases and traits that could be avoided. Well, doesn't the metaverse have that to offer at least once it gets to a point where it feels as viscerally real as the world that you and I are in today. And at that point it's like, well well in the metaverse I don't have to be short.

I don't have to be chubby or scrawny. I can be ripped. I could be six, five. I can change my eye, color, hair, color, skin color, whenever I want.

[00:14:30] Dr. Janet Bruno-Gaston: Yeah.

[00:14:30] Griffin Jones: And I don't even need to maintain this physical form. I can go to another one. I could have children in the metaverse and so.

[00:14:38] Dr. Janet Bruno-Gaston: It's scary.

[00:14:39] Griffin Jones: I don't have a question there. I don't, I just. You can respond to my.

[00:14:43] Dr. Janet Bruno-Gaston: You can go, you know, AI is infiltrating every, every aspect of our society. We're not gonna be able to evade that. It's interesting to see it in medicine and that's changing our field as well.

But I mean, you're right. I don't even think we can fathom right now, what that's gonna look like. For, for the younger generation growing up, it's just gonna be so foreign. But I imagine as the technology improves, like you said, and they can address all senses so that you truly feel like are existing in this virtual world then yeah.

[00:15:22] Griffin Jones: Well, let's get back on solid ground and you gave me a good segue. You set me up well, which is that artificial intelligence is changing every aspect of everything much, certainly our field. How about fertility preservation in particular? How has AI changed it in the last three or four years or are most of the changes still to come?

And if they are mostly still to come, what do you see on the horizon?

[00:15:47] Dr. Janet Bruno-Gaston: I think most of the changes are still to come. I don't know if it's specific to fertility preservation, but I will say that there's a, a lot utility. And research going into the use of AI in the lab. And that's because a lot of what we do, a lot of what the embryologists do to their credit is monitoring and picking up and looking for non-invasive markers of embryo viability.

And I think AI just as it has done in radiology and pathology has been shown to be more active, obviously we need to program it. So the system only works based on what you put in, but I think over time a lot of what happens in the lab will be taken care of by AI. And it may lead to better surveillance of embryos.

It may lead to new markers of embryo viability, new ways for us to assess viability to your point about a specific example in fertility preservation, one of the things that's difficult in counseling patients is. What is a good number and yes, we have studies looking at the outcomes from women who do oocyte cryo preservation, but at the time of a cryo, we really know very little about the health of the egg outside of morphology and maturity level.

Well, there are a lot of studies looking at metabolic competence. Right. So what is happening from a developmental standpoint to suggest that this egg is healthier than the other, and they're using microscopy and fluorescence imaging, and all of that can be streamlined with AI to kind of help better counsel patients on what this means at the time of cryo preservation and preparation for future family planning.

So I do see a lot of work there.

[00:17:37] Griffin Jones: Is it mostly to come because the technology's not there yet, or the business model isn't there yet? Or is it because clinics and labs are slammed and they might not be as adopting the newest possible technology as quickly as possible because they're so busy.

Which of those is it?

[00:18:00] Dr. Janet Bruno-Gaston: I think a little bit of both. I do think the technology is there it's being used in other fields. I think we have been slow to adapt a little behind in that sense and, and part of it and to their credit embryo ologists, they are very particular, there's a very type a personality and there's ownership in, in what they do.

And obviously as a clinician in debt, because I can only do so much what happens in the lab impacts my patient's outcomes profoundly. And so I think that would be a bit of a culture shift for them taking away what they have been doing primarily for, since the inception of this field.

So I think that may be a little bit. Uncomfortable for them and perhaps for us too. So I think the technology is there. There's not enough data to support it yet. But it's coming.

[00:18:52] Griffin Jones: It's coming well, embryologists are so busy right now that even if they're, even if they became the case manager of more cases, but their own, or at least that part of their workload is reduced.

I don't see them going out of work in the next 10 or 20 years. I think we're we're, I believe David Sable when he says we're only doing. 200 to 250,000 cycles of the 2 million that we should be doing in the United States. And for years it really seemed like the clinic was the bottleneck.

And it was like, okay, well, we can't a lot of, at least maybe since 20 17, 20 18, a lot of clinics were busy, but they could still do more cycles in the lab, if they could convert more patients to treatment. Now it's probably three quarters of labs are slammed too. And so I don't see that going out of, out of work and I wonder what what I wanna talk more about the oh, LA and artificial intelligence are adopting it from your vantage point, because probably a couple times a month, Janet, I get.

Hit up from startups in the IVF space that are in AI mm-hmm and some of them have way too much homework to do. It's like, go prove your concept first and then gimme a, but some of them it's like, this is legit. And they're having as hard of a time as anyone getting their product to market.

And seems to me like this could solve a big problem. So can you talk a little bit more about I don't know if you can think of any examples or Or just maybe why we haven't included AI in fertility preservation as much as perhaps it should be.

[00:20:28] Dr. Janet Bruno-Gaston: I think there's still a, a bit of fear of not about how this will replace me. But just some fear about trusting that what we do and the stakes that we take with patients as much as possible, we strive for perfection. And so committing a patient to a, that you're not comfortable to. It's a very difficult transition for both clinicians, theologists and researchers, and we should be critical and we should be hesitant to adopt things. Because our field, all of the iterations of that with developmental and how that impacts offering in generations, like we have to be steadfast and holding to a certain standard because we are the gatekeepers that ultimately this technology could impact an entire generation. So I think a bit of it is fear. A bit of is anxiety with change and not feeling comfortable yet. And I think the data is still lack.

I think, I think there's still room for us to have more robust. Data to support that science, but the technology is certainly there. The technology is certainly there and it's being used in other fields. And I think it will just take time before we feel. Comfortable with that. I mean, even onsite cryo preservation was experimental until 20 12, 20 13.

We've had the technology of, of how to do that and it's evolved and improved, but it still took some time. It still took some time for us to be comfortable with that.

[00:22:02] Griffin Jones: So you were, you were talking about Using AI for embryos a little bit earlier. Is there bigger opportunity for oocytes? And I know someone who's doing that, I don't know that I can, or that I will, I won't say their name right now, but if people are interested, they can email me privately.

But one what , the value they purport to bring proposed to bring is that there isn't a way of being able to grade oocytes other than just theologist, examining EEG, but that there's an opportunity for artificial intelligence simply by compounding all of the possible learning that it can do.

Is that an area that you've seen or, or is most of the AI that you've seen been geared toward the embryo?

[00:22:46] Dr. Janet Bruno-Gaston: Most has been geared towards the embryo. But I brought up just the fluorescence imaging because I did a lot of research with PCOS and looking at mitochondria and mitochondrial health and how that translates into embryo health.

And one of the things we came across in partnering with the core microscopy at Baylor is just that they have a lot of fluorescent imaging techniques to look at without getting too scientific, but redox potentials and just markers of metabolic competence. And that could be potentially something that is another marker of oocyte viability and does, and can be used at the time of cryo preservation to more objectively counsel patients about what they have at the time of freezing. And that's something that can be trained through AI, once you start to figure out algorithms and track outcomes so.

[00:23:46] Griffin Jones: When do you feel like we became ready for prime time or do some people still have a way to go?

Does it depend on the lab? Does it depend on the clinic becoming ready for prime time for fertility preservation in the field? Because I'm not a clinician sometimes that makes me ask dumb questions, but sometimes, it gives me a perspective of looking at this from someone who is not educated about it, which is the majority of patients, their first.

Go around and one concern had been that, well, we, we know how well these eggs freeze, but we don't know how well they thaw and so when do you feel like we became ready for prime time for fertility preservation to market it, to offer it to the majority of patients who could benefit it from it?

Or does it still depend on the lab? Are there still people who aren't ready for prime time?

[00:24:37] I just got back from the Association of Reproductive Managers Meeting in Atlanta. And you know what everyone was talking about? Every embryologist, every nurse, every manager, every practice owner that was there was talking about burnout. That's what everybody's talking about everywhere, by the way. And every aspect of the workforce. Everyone's talking about burnout and we can keep trying to replace people who also seem to be burnt out. The people that we're bringing in are burnt out from something else. So that's one solution. We can also do things to make the log lighter because when you take 10 people, on a log and you take four of them off those six people are burnt out.

So if you can't put four more people back on the log, or you can't put six more people back on the log, you have to make that load lighter. And one way of doing that is using Engaged MD. And I'm at a point now where I feel like it could be a real disservice to your staff, to not be using Engaged MD at the point where so many of your staffs are overworked.

So many of your labs are slammed, but also your managers, your nurses, your billing team. That anything that we can do to take things off of any of their plates, especially we're not just taking something off their plate in the moment, but we're also using that to make their interactions and lives with patients easier and better beyond those tasks, we should be using it. And that's what Engaged MD does.

Your nurses and your care staff should not be doing things like telling the same thing to the same patients over and over again, when the patient has too much information to absorb, but time anyway, when they could be talking to really educated patients, meaning that you've educated them by using Engaged MD's platform ahead of time having a, a smaller window where they're repeating things and not having to do things like track down consents because Engaged MD does all of that for you.

Burnout is it's the worst that I've seen since I've been in the field. If you can replace all of your people and, and overstaff, 'em great. Most of us can't. And so when we have to use technological solutions. And for those of you that are listening, Engaged MD is already in more than half of practices out there.

And if you are not there, you're now on the wrong side of the bell and it could be at the expense of your staff. And so I hope that you'll use the opportunity to go to engagedmd.com/irh. They'll give you 25% off your implementation fee. If you use my name or you use Inside Reproductive Health mentioned that you heard it on the podcast, but don't do it for me.

Do it for your staff, engaged md.com/irh. Now back to my conversation with Dr. Janet Bruno.

So when do you feel like we became ready for prime time for fertility preservation to market it, to offer it to the majority of patients who could benefit it from it?

Or does it still depend on the lab? Are there still people who aren't ready for prime time?

[00:27:51] Dr. Janet Bruno-Gaston: I don't think so. I think most people are very comfortable fertility preservation, I think once ASRM removed the experimental label. And we had all of the studies looking at long-term outcomes, most people were very comfortable.

Now I will say that there's certainly an increase in to see, because you have a lot more celebrities talking about fertility preservation. It has infiltrated social media. And so it has a bigger platform primarily through the work of the patients. They have been advertising this more for us than we have.

If I wanna be honest about that and through that need, I think is what has drawn our attention to say, Hey, this is something that they value. This is something that's important to them. And so, because it's important to them, it has to become important to me.

[00:28:39] Griffin Jones: I was gonna ask about the, the advertising part coming from the people are seeing celebrities talk about it and, and.

And following them on social media of their journeys. Is this an area that is still under referred from other provi even before let's even before we get to the elective side, even on just the ENCO side, is this still under referred from other providers?

[00:29:03] Dr. Janet Bruno-Gaston: I'm so glad you said that I embarrassingly so, embarrassingly so, it is difficult to create a network that geographically spans a large region outside of a metropolitan hub, like Houston or big cities that you mentioned. So that really creates a disparity for patients on what they're able to be offered. If they're offered in what they're able to receive it in a timely manner.

And to me, that's just uncomfortable. Because this is a standard part of REI that, , any group should be able to perform for patients. And the fact that there are these disparities that exist one city outside of here is, is just very disheartening. But to your point, this is not even entering into the elective space.

This is speaking in just medically indicated. I can't tell you how many patients I see after chemotherapy and they say to me, well, No one told me, they said that I should kind of check it out after, or they mentioned it briefly, but in the midst of everything that was happening, that was difficult.

So I really tried to prevent myself as a resource. I reserve spots so that if patients need to be seen immediately, they can come in. I've assembled a team that we kind of get things started in a very streamlined way. I partner with local pharmacies to be able to get medications delivered within 48 to 72 hours, if we need to do random starts.

So those are things that I put in place, so that if I can make this process easier for them, both their provider and the patient, then they will be more receptive to referring to me and allowing their patients to go through a treatment before they come back.

[00:30:56] Griffin Jones: It seems to me again, this is coming from a non-clinician, but it seems to me almost negligent to not refer to an REI as if, especially if someone was about to go through chemo. And I probably wouldn't have believed that happened at any kind of scale, but I was in my home city. I was talking to an oncologist at a social event, had nothing to do with work, told her about what I do for a living.

She had no idea of the REI's in our town. She had never referred out and she said, oh, maybe, yeah, I should start doing that. It's like, yeah, maybe you should.

Why don't you go ahead and do that. So is it because, I mean, do they think that they just have, so, I mean, they do, they cancer of course is life and death in many instances.

And so maybe I'm asking you to speculate, but I'm asking you to speculate why do you think that It's not as broadly toted of a message.

[00:31:55] Dr. Janet Bruno-Gaston: Yeah. I mean in their defense, there is a lot going on. There is a lot going on even emotionally for the patient and the provider. And so in the midst of this long discussion that they have to talk about, they then have to remember also bring up fertility preservation.

And so I think in the long list of things that are a priority for them to get through with the patient, fertility preservation may be somewhere on the bottom or doesn't exist. I also think that there is an assumption as providers we have our own bias as much as we try to ,exclude them that one, this process is expensive.

It's timely. You may not be able to afford it. So what is the purpose of going through all these hoops just to say, well, I'm not gonna do it anyway. And so I've had patients come back and say, well, providers said, Hey it's expensive. It's out of pocket. You're probably not gonna wanna do it.

And when you present the option like that that really isn't counseling the patient in a very neutral way. And so I think a lot of what I try to do is even if it's just a quick fact sheet that I'm like, Hey, you can pick this up and take in your office so that they can save their visit to do their counseling.

And the patient can then read about this and contact the clinic as they need to is a compromise between us both. I'm just really too trying to make their job easy without taking up much time from the primary counseling that they wanna do.

[00:33:26] Griffin Jones: Is it the same with elective fertility, press for OB GYNs. Do you suppose that they're not doing, and maybe this is an assumption, but from what I'm gathering, they're not doing a whole lot of family building counseling. They're treating people who need to be treated. They're referring to REI's once they, once they encounter infertility or once they encounter something like endo or, or P C O S.

But just from a oh, you're 32 and this is what you want next in life. I don't know that's happening. What education needs to be bridged for the fertility preservation side for referring providers?

[00:34:04] Dr. Janet Bruno-Gaston: So to your point with generalists, I actually do think they do quite a bit of family planning and family planning in our world is always expansion, growth, wanting kids, but family planning in their world also includes contraception.

So they do have very clear conversations with patients about what are their family planning go OS and what I will say for the elective for fertility preservation. I would say the patient leads that referral. So most times when I get patients coming in for elective, fertility preservation, it's truly something that they advocated for themselves.

They said, Hey, I heard about this. I wanna know this can I see someone? And that's how they come 'em to me. Or if they come on their own accord directly to REI. They come in, well read about, about the process and, and kind of have an idea of what it looks like. So it's interesting. There there's a little more initiative there because they have a very clear goal versus from the uncle fertility perspective, this may not have been something you were even ready to think about.

And now I have to pose this question to you. So the that's my thought there. And then in terms of just how do we improve referrals from, from, from providers across disciplines? I think like you said education making them aware that this is accessible, this can be done in a timely manner.

We're welcome to collaborate, to help coordinate care with patients so that we don't create treatment delays and that compromise their cancer diagnosis or their treatment outcomes. So a lot of what I do is just education and lending myself as a resource. And like I said, creating as simple as a.

A patient fact sheet with your card and your clinic's information is an easy way to walk into an oncology office. Maybe it's Heon or , surge on. And you just come in and you're like, Hey, I'm an REI in the area, I have a strong interest in fertility preservation. If you come across patient patients feel free to refer them.

This is a patient fact sheet. They can read this in the waiting room while they're waiting to see you. And if they have any follow up questions, they can contact me directly. That makes their job easy. I haven't taken up counseling time from what they need to, to get across to the patient so for them that works.

[00:36:32] Griffin Jones: So we talked about referral patterns. We talked about referral tactics. We talked about some Terminator, two stuff. We talked about your interest in fertility preservation as a practice area. I wanna go more into practice areas in general, because there are younger docs listening and thinking of, of what that will be.

So how do you delineate those duties among a group of so I think we can say now that you're, you're part of the center of Reproductive Medicine in Houston, which was a, a six, seven doc group.

[00:37:03] Dr. Janet Bruno-Gaston: It was prior to me joining, there was four. I replaced one physician and one retired. So there's four of us now, but we're kind of like acquiring more.

So we're getting there.

[00:37:14] Griffin Jones: You got some more docs coming and I even know one of them. And then you also have a big announcement as joining one of our bigger groups, the Shady Grove group and so when one's doing that, and in your case, we're talking about fertility preservation, but for other people it's gonna be recurring pregnancy loss.

It might be, and might be endometriosis. It might. How does that work within a practice? Or how could it work? Because I imagine the way it works varies differently from practice to practice at some places, it's probably just a title at other places, it really is a practice area. And so what does it mean to actually have that practice area?

[00:37:51] Dr. Janet Bruno-Gaston: Yeah. So I definitely agree that can manifest differently depending on the business model and practice you join for me, I knew that I wanted fertility preservation to be a part of my practice. And so I made that very clear on my interview. So for the fellows and recent grads, if there are something that you want to continue to pursue, perhaps it was in line with your research, your thesis from fellowship.

Be clear about that on your interview, because oftentimes the practice is excited about that because that becomes an area that they can then advertise and market and tap into that they probably are doing a few fertility preservation cycles here and there, but if you're, you're passionate enough about it, and you're thinking about becoming a center for that I think that's actually a selling point on, on an interview for you.

And so I talked very candidly about my interests on my interview and set some for myself and I'm happy. To be able to be achieving those goals and creating partnerships that improve access and more importantly coverage for fertility preservation. And from a business side, those partnerships are important because that becomes another pipeline for you to get referrals for patients.

So that has been helpful for me. And that has been my approach in, in kind of carving a niche for myself and getting to know clinicians in the area that you work. I mean, medicine is always a small community, but it can be joining local societies going to meetings just so that they have a face with the name.

And that could be the way that you start getting referrals from an office persistently. So I say definitely network make sure that you partner that you're partnering in line with your career goals and, and be consistent with that.

[00:39:50] Griffin Jones: So I see the selling point for you, Dr. Bruno guest honored you, the physician, you, the fellow whoever's listening as a different differentiator and a way to build your practice pretty quickly.

What about though, making sure that you are not sold by the clinic, by the practice owner, by whoever fellows are scarce right now, Janet, there's 44 of 'em. They're always scarce, but maybe only maybe only 20% of people would've hired 10 years ago. I don't know. But now it's like anybody is trying to get a doc right now. And so oh yeah, you wanna have a fertility preservation pregnant? Of course. Sure. We'll name it the Janet Bruno guest on fertility preservation consult room. You have any deceased grandparents? We'll name the garden for them. So like, most people, I believe in our field, I do believe the vast majority of people in our field are ethical. Really good people. There's probably a couple that aren't, but it, but they're they're I do believe they're the exception. Most people are here with great hearts very often though even the people with great hearts. Sometimes they just want to, they just wanna get the deal done. Not cuz they're bad people, but they're just like, oh yeah, Jan

sure. Yeah. That's what you wanna do because they don't really have a clear picture of it. In their mind and they're willing to put whatever placeholder there without firmly checking it against the, what, the picture that the candidate has in their mind so.

[00:41:14] Dr. Janet Bruno-Gaston: Yes.

[00:41:15] Griffin Jones: So I'm cautioning people right now. This is advice that I may or may not be qualified to give, but for the people listening if they have a practice area in mind and what that entails that they should be getting that clear picture from the hiring group mm-hmm and, and making sure they're in accordance and, and probably making sure that it's in writing simply because again, not because most people are unethical, but because writing just helps to really firm up X expectations.

Yeah. And so what did that have to look like for you or, and what does it have to look like for someone that's really serious about a practice area?

[00:41:49] Dr. Janet Bruno-Gaston: No I definitely agree with you. You wanna know that they're gonna be able to support that, that they respect that and they understand that that's something that is a part of your career goal.

For me, I kind of laid out a plan. I said, this is what I want to achieve by year one, I had a goal of working with some specific organizations. The mission is a nonprofit that provides grants to fund fertility preservation cycles. They do require a contract with the clinic. And so I told them very candidly, Hey, this is an organization that I would profit with partner with, how do you feel about that?

Have you done that in the past? They very receptive to that. And I kind of, because I worked one of my mentors, Dr. Woodard at MB Anderson, I had a sense logistically of how she had things set up. And so meeting with my nurse, I said, Hey, , what's my nurse's experience. ? Who would she be open to, I mean, I met everyone during the interview process you can take as many visits as you want.

That's something like, I didn't know either. I had a lot of people that said, Hey, I went back to the practice and like kind of just shadowed a day to work with them, to get a feel for the culture. So when your interview and considering practices. Yes, reviewing the contract and, and having a lawyer look over that is important, but there's also just a sense of culture that you want to assess.

And that's hard to get that from just reading black and white. And so a lot of times, I just came back up there and was like, Hey, I'm gonna kind of shadow today. I wanna see, the feel, the flow of clinic and those things. And I was asking the nurse would you be open to that?

What are your thoughts about that? Just getting a sense of how hard was this gonna be for me to build? Yeah.

[00:43:31] Griffin Jones: You could see how is she fighting? Yeah, because they'll say whatever, but the nurse, if the nurse is like, yeah, yeah. Then I'm doing that. You can get a little bit of an indicator.

That's a good idea. It's really good idea.

[00:43:41] Dr. Janet Bruno-Gaston: We talk to them, the people, the support staff around you like everyone from the front desk to the ma, because you really get a sense of perspective from everyone's everyone's job. So that to me, made a difference. I'm someone that has a strong instinct. And that means more to me than a lot of things.

[00:44:01] Griffin Jones: I'll let you have the final thought, whether you want it to be on fertility preservation on building a practice area within a practice there aren't dystopian futures would, how would you like to. On the better coating remarks on the metaphor.

Yeah.

[00:44:17] Dr. Janet Bruno-Gaston: No, I mean, thank you for having me on, I mean, this is a great afternoon for me to, to talk about fertility preservation.

It is something I am extremely passionate about, and as you can see it. The fact that we are not getting appropriate access to care, the healthcare disparities that exist across so many different communities. It is important for us as Reis to really champion that cause and make sure that we are constantly trying to advocate for those patients and provide betters opportunities for future family planning.

Because that is really important both for medically indicated patients. And for those who decide to choose fertility preservation, electively there are great organizations out there who are invested in, in helping practices, improve access. So for those of youngs musicians or anyone who decides, Hey, this may be an interest of, of, of mine.

Please check out the chicks mission, Baby Quest Foundation. These are great nonprofits that are strictly looking for clinics to partner with, and they are on the ground. They are lobbying for legislation to improve access and coverage to care. And they're just looking for REI clinics to partner with so that they can and have patients come through so.

[00:45:40] Griffin Jones: We'll link to those organizations in the show notes, Dr. Janet Bruno Gaston. Thank you so much for coming on Inside Reproductive Health.

[00:45:48] Dr. Janet Bruno-Gaston: Thank you.

Thank you.

The Fertility Website Rip Off: 6 Tips to Protect Doctors

By Shaina Vojtko and Griffin Jones

Let’s just hope fertility doctors aren’t paying attention

Most fertility practice owners redesigned or built a new website in the last decade, and they might be getting hosed.

The website development-marketing problem isn’t unique to fertility doctors. If you’re the executive of a fertility company or any business for that matter, these tips are equally relevant to you. There’s just an established category of marketing companies that takes advantage of physicians and some of them have concentrations of fertility doctors.

The problem: paying for website maintenance with a big marketing markup

Your new website project is finally complete and search engines are starting to reap the fruits of your labor.

Now, regular updates and maintenance are crucial to keeping your site running at full capacity. In most cases, the first touchpoint a prospective fertility patient has with their provider is their website.

Security is the primary reason that website maintenance is so important. When you don’t make website maintenance a priority, it’s easy for hackers to find vulnerabilities. With a few clicks, they can easily target an outdated site.

As a marketing tool, your website was designed to provide information and turn visitors into new fertility patient inquiries. An up-to-date site and content management system (CMS) demonstrates credibility and communicates that it is safe for visitors to submit their information to you.

And because security and maintenance are such a need, some marketing companies take advantage. They bundle in low return marketing services and mark up what should be a low cost expense.

We’re not talking about small firms with good hearts that struggle with keeping the mission (scope) from drifting, while not being so rigid that they fail to help the client when they could meaningfully do so. That’s a natural tension that all client services firms face.

No, we’re talking about large medical marketing agencies whose business model is undeserving doctors by scaling their overpriced packages, including arbitrary blog and social posts, or ambiguous ongoing Search Engine Optimization (SEO).

Make investments, pay expenses, and know which is which.

Remember a $10,000 expense that generates nothing is more expensive than a $2 million investment that generates $5 million. Return is more important than cost, though the higher cost the bigger the problem if there’s no return.

The best way to keep your fertility company’s website updated and protected from hackers, while not overpaying for it, is to have a website maintenance package that is separate from hosting and from your marketing investment.

Here are six tips to help you:

1. Your marketing agency can hire a developer, but don’t hire a development agency to do your marketing

Digital marketing agencies and website development agencies were usually one in the same in the early days of the internet. Because each has become so specialized, it’s far more effective for them to partner than to try to do it all.

Fertility Bridge, for example, has done, and will do, plenty of website builds and redesigns…but we are not a dev firm.

For the convenience of our clients and for the continuity of branding and messaging, we have preferred developers on our contract team with whom we’ve partnered on many successful fertility websites. We can use them and include the cost of development in a one time project. Or we can use the client’s developer while we provide project management and design.

2. Quote maintenance separate from build

Ask for the cost of ongoing website maintenance, including security and routine updates to be quoted separately from the site build.

You may need continuous improvement in marketing and business development but keep those separate from the maintenance of a new site. Again using Fertility Bridge as an example, after we redesign or build a new website, the minimal maintenance agreement is between the developer and the client, completely untethered from the client’s engagement with us.

3. Budget for both website hosting and website maintenance

While both have associated costs, web hosting and web maintenance are two separate functions. Both are necessary for the health and existence of your website. The main purpose of web hosting is to get your website live on the internet so people can access it.

4. Keep the hosting cost the smallest

When budgeting annually for maintenance fees, don’t forget to budget for hosting costs, too. You can expect to pay anywhere from $25-75 per month for hosting with an annual contract from WP Engine.

In order to keep your website online, you’ll need a reliable web host. While there are plenty of options for hosting providers, make sure to pick one that is designed for speed. A fast loading website is key to a strong user experience and good Google rankings. We recommend WP Engine or DreamHost but strongly encourage you to take the advice of your developer as they are well versed in the specific needs of your website.

5. Use this checklist to select a good maintenance plan

A good maintenance plan covers security but should also take into consideration routine content updates and changes to website pages.

• WordPress Core Updates

• Theme and Plugin Updates

• Security, Uptime Monitoring, and Hack Clean-up

• Regular Back-ups

• Access to Support Resources

• Content Management*

• Performance Optimizations

While package costs can vary significantly based on the level of customization and care needed to handle your individual site, it is reasonable and typical to see costs that range from $500 annually for lean updates to $5,000 or more annually for robust updates.

6. *Have someone on your team that can update content

Minor content updates are a tension point between fertility companies and their agencies. Minor updates are those like

• Adding office hours for satellite office on location page

• Removing staff member from about us page

• Changing PGD to PGT-M on old blog post

• Deleting Zika pregnancy warning from home page

Sporadic requests like these are not a good use of the developer’s time to receive, nor yours to send.

You don’t need an employee to create major pieces of content, a marketing agency can do that. You need someone inside your organization who can make content updates to your website. If you’re a giant fertility company you may have a whole team, but even a small REI practice needs at least one person who can access your website’s CMS.

*Being able to make content updates is not the same as having the relevant skills to properly maintain a website. If your team member causes an error while updating a page, you need to have someone retained that can fix it.

INVEST FOR RETURN, KEEP FEES SEPARATE

Sometimes fertility companies have to invest a lot in marketing, but it should be for the return of future value. Don’t buy services you don’t need because they’re bundled with something you do need. Keep website maintenance separate from build, hosting, and marketing. Train someone in your organization to make minor updates to your website. Follow these six tips instead.

If you think your fertility website is preventing you from reaching your business goals, consider Fertility Bridge’s strategic guidance to determine how it plays into a greater market or brand strategy.

Start your business assessment with our Goal and Competitive Diagnostic for just $597 here.

Good and Bad First Impressions: 6 Pillars of a New Fertility Patient Concierge Team

By Kathy Houser and Griffin Jones

“You only get one chance to make a first impression”

Think about how important it is to a fertility practice. You can invest everything you want in branding, advertising, and a nice building. But if your prospective patient's first interaction with your team betrays that first impression, the result may be even worse.

First impressions not only get people in the door, they set the expectations for the process in which fertility patients need to trust you all but implicitly. In order for the first points of contact with your clinic to be the gold standard of concierge service, their goals must be aligned with those of the practice and the patient.

That’s why we’re using the broad term of New Fertility Patient Concierge Team instead of separate terms like call center, digital chat team, or new patient navigators.

In other resources, we’ll talk about the structures of those roles, but in this article, we’re giving you the six pillars for aligning this team with the measured growth and improvement of your IVF center.

They are

1. Practice Goals

2. Team Outcomes

3. Team Profile

4. Education/Coaching

5. Recognition/Evaluation

6. Incentives

1. PRACTICE GOALS:

New patient concierges aren’t just people that answer your phone. They positively or negatively impact at least four major business goals of any fertility center.

1. Patient satisfaction

2. New patient visits

3. Specific provider volume increase

4. Targeted region/office volume increase
   

When the roles aren’t aligned with specific practice business goals, the systems for how they are evaluated, incentivized, and hired become expensive and counterproductive.

2. TEAM OUTCOMES

The New Patient Concierge Team doesn’t have total control over the business goals, but you can measure their impact by these key performance indicators (KPI):

1. New patient appointments scheduled

   • Total

   • By team member

   • Relative to goal

   • Year over year

   • Month over month

2. Conversion to appointment

3. Cancellations rescheduled

3. TEAM PROFILE

To put the right person in a concierge seat, we are looking for someone who is lower (but not too low) in competitive drive and high in empathy and compassion. They take pride in being a resource.

To find the right candidate who does not mind repetitive actions and thrives on helping others

1. Use a personality assessment

Such as The Caliper Profile. For empathy, this test screens for “a combination of traits that can help you see how well a person reads a room” and “Are they flexible or rigid?” That’s extremely insightful when hiring someone who has to be responsive to customers or in our case, patients. Once an applicant or employee takes the Caliper Profile their results are measured against one or more validated job models. For this role, the candidate needs to score high in critical competencies such as “relationship building” and “composure and resilience”.

In Meyer Briggs for example, the perfect fit might be a Discoverer Advocate. The obligatory disclaimer on personality tests: They are a useful tool for seeing how likely someone is to be a good fit for their seat. One’s tested personality type does not universally qualify or disqualify them from a role.

2. Promote the mission

Promote the sense of pride of providing people struggling with infertility with hope.The life changing and highly personal service they provide is a motivator, for the right people in these seats.

3. Pay above customer service industry average

The cost of living index varies across markets, but the range for a concierge customer service person is between $20-$27 per hour.

If the range seems higher than what you would pay for someone who isn’t exceptionally money-motivated, consider two things. The first is the rate of inflation and the increase of resignations and wage expectations in 2022. The Great Resignation is occurring amid rising inflation, and as employers face the tightest labor market in recent history. The latest inflation reading from the Consumer Price Index (published 12/10/21) came in at 6.8%, the highest year-over-year increase since 1982.

The second is the outcomes for which these personnel are responsible for achieving. When their alignment with growth in business goals is measured by the aforementioned KPIs, they’re clearly worth the investment. We will further detail how to outline their incentives with the goals of the fertility practice.

4. EDUCATION/COACHING:

Your call center and new patient navigators must be experts in particular topics about the clinic and infertility. There can be no concierge level service without mastery of the material.

There are at least twelve elements in the syllabus that every call center and new patient concierge must know cold. If you’d like Fertility Bridge’s curriculum for new patient concierges, we provide full guidance for this in our Lead Conversion System.

Lastly, in the bucket of education and coaching, if you find that a particular team member is not performing to the level of the others, it is necessary to “coach up” or move them out of that role, as a negative attitude or lack of skill set frustrates and demotivates the rest.

5. RECOGNITION:

Methods of recognition create an atmosphere of team and individual accomplishment. They reinforce that all team members are striving for the same goals and success.

It is important to systemize recognition above other incentives to support the natural personality motivators of the concierge team.

Here are four ways of motivating your concierge team using their own internal drivers:

1. Tally Board

2. Practice-wide email

3. Thank You Board

   • In which anyone can post a thank you to anyone else in the office.

   • Where staff and potentially patients can see it. Keeping it in staff only areas such as the kitchen won’t allow patients to appreciate your amazing culture of internal support.

4. Patient Compliment Repository

   From social media, online reviews, patient satisfaction surveys

6. INCENTIVES:

You’ve intentionally selected people who are motivated by helping others and you’ve established a system of recognition to ensure they perceive that benefit of the job.

Because the tasks of an ongoing new patient welcome team are on-going, every day, endeavors, we have to be careful about additional incentives. We don’t want to book new patient visits at all costs. Hiring someone who is too high on competitive drive and gearing their compensation plan too much toward booked appointments is a recipe for pressuring new patients. We don’t want that.

We do want to help people who are struggling to build their family to be able to get expertise from a fertility specialist.

Using incentives for reaching goals should be limited and attainable, otherwise, you will do more harm than good.The incentives should:

1. Connect to one of the desired outcomes whether it’s for the team or an individual

2. Review and recognize weekly

3. Reward monthly or quarterly

4. Reference core values

Rewards for Achieving Goals

• Gift cards

• Customized gift baskets

• Event tickets

• Team lunch

• Use of desirable parking spot for a week if employees are on site

Align Your New Patient Concierges’ Goals with Those of Practice and Patients

The folks you hire to answer your phones are so much more than just that. They are the first point of contact for potential patients, they set the tone and convey confidence and knowledge from the first interaction. Employ the six pillars to set your concierge team up for success. Use personality assessment tools, hire well, train and invest in the people who greet and attend to callers into your practice and you will see the benefits over and over again.

Fertility Bridge has a proven system and dedicated staff for improving and empowering new fertility patient concierge teams. If you’d like our help, enroll in the Goal Diagnostic here and we will be happy to discuss the framework with you.

5 Steps To Improving Your Fertility Clinic’s Online Reputation

By Griffin Jones

Yikes.

It’s no different than what many of us do when choosing a new hair salon or restaurant, they search online. 

Years ago online reviews of doctors were scarce, and even fewer considered trustworthy, but times have changed.  

 According to a survey from MobiHealthNews, 95% of U.S. adults believed online ratings and reviews to be reliable.  Even more interesting, 70% of those surveyed said online ratings influenced their choice of doctor. 

With the increase in prevalence and weight of online reviews, today it’s more important than ever to take action and proactively manage your clinic’s reputation by following the 5 steps to improving your fertility clinic’s online reputation.

1. Provide Concierge Service

2. Claim & Maintain Listings

3. Request Reviews

4. Manage Reviews

5. Market Reviews

Let’s break down each component. 

1). Provide Concierge Level of Service 100% of the time

While putting systems and services in place to improve and maintain an online reputation is necessary, your clinic must first have a concierge level of service written into the fabric of its DNA.  The clinic leadership team must have an unwavering commitment to offering a concierge-level of service at every turn, and mandating its employees to do the same. 

Offering concierge-level service is thinking about the small things and asking yourself, What Can I Do To Remove The Patient’s Pain In This Moment? Examples include, but are not limited to: 

• Using the patient’s name during conversation 

• Having call center / new patient coordinators use the patient’s name immediately 

• Always remaining calm and using a pleasant tone of voice

• Providing patients with support/messages of hope during the two-week wait.

 If this belief and level of customer service is not woven into the fabric of your culture or expressed within you as a physician, it will affect how your staff treats their patients.  

2). Claim & Maintain Listings 

Once offering the concierge level of service has been addressed, the next step is to organize your listings.  Local Listings are a directory with your business's key information. When people search for your business (or the service you provide), your listing is usually displayed in the search results.  The most important listings are:

• Google My Business (GMB)

  • Physicians should be tied to the clinic listing, but owned by the physician 

  • Each clinic location should have a listing, including satellites so reviews can be left

• Facebook

• Yelp

  • Yelp is important because it is also integrated with other listings sites, like Bing and Apple Maps 

• Fertility IQ

  • Fertility IQ has skyrocketed as an influencer platform over the last few years, and the length, depth, and detail of the reviews have it becoming a recognized source of patients’ trust. 

Once Google & Facebook are at a minimum of 4.5 and 60+ reviews, begin to focus on Yelp & FertilityIQ

3). Request Reviews 

Patients will always leave reviews when left up to their own devices, but if you want to achieve and maintain a rating of 4.5 and above, you need to be proactive about asking and automating review requests.  

Asking 

When you’ve treated patients right, they want to help you.  Therefore, ask the right patient for a review and give yourself and your staff permission to do it.  While verbal requests are necessary, asking also includes creating marketing materials that advertise where to leave reviews and post the requests on social media.  Bottom line: Don’t be afraid to ask with the right patient!  In your waiting room, use video to ask satisfied patients to like you on Facebook, rate you on Yelp, or fill out a patient satisfaction survey.  Seek patients who give your practice high marks and ask them if they’d be willing to give you a testimonial. 

Automation 

Using a service that automates repeat requests to reviews and pushes them to the four most important platforms in Reproductive Medicine (Google, Facebook, Yelp, FertilityIQ).  The software element helps ensure the patient is reminded and the review is pushed to the platform where you need it most.

4). Manage Reviews 

It’s critical to respond to 100% of reviews - both positive and negative.  While it’s also helpful to have a foundation of scripts to utilize so that responding on every platform is not tedious, slight customization is necessary to ensure the consumer’s needs are being addressed.  Something as simple as “Thank you for your feedback. We’re committed to a better patient experience and are in the process of reevaluating all staff communication” will show the patient you take their feedback seriously.  And to the prospective patient who hasn’t yet chosen your practice, it lessens the harshness of the review.

5). Market Reviews 

You’re collecting the reviews, now it’s critical to share the positive patient feedback with other prospective patients still in the decision-making phases.  Our internal data shows that at least 50% of patients will conduct an online search of the clinic, often landing on your website, to evaluate a practice.  Highlight positive reviews and testimonials right on your home page so they aren’t missed. And if your center does not have amazing, professional patient testimonials that blow folks away, it’s time to get that changed right now by consulting with the creative team at Fertility Bridge.  

By taking charge of your online reputation, you will impact the number of new patient appointments, retrievals and ultimately, revenue.  

If you’d like Fertility Bridge’s help in improving your online reputation, we can assess your situation in the Goal and Competitive Diagnostic.

128: Meet ma(+)e fertility the Uber of IVF with Gabriel Bogner

On this week of Inside Reproductive Health, Griffin Jones is joined by Gabriel Bogner, co-founder of Mate Fertility—a leading disrupter in the IVF space.

Did you know—nearly 20% of the time, it takes more than two people to make a baby? And yet, only 1.7% of those dealing with infertility seek or receive the treatment they need. Gabriel and his team of fertility doctors believe the best science should be available to the most people. And at ma(t)e fertility, they’re working to make this possible.

Listen to the full episode to learn:

-How Mate Fertility is disrupting the IVF space with affordable, accessible IVF treatments

-How traditional OB-GYNs can get set-up with a Mate Fertility clinic in less than 6 months

-And what the future of Mate looks like for both IVF patients and clinic owners

Inside Reproductive Health is sponsored by EngagedMD. For technology that educates your patients with true informed consent, visit engagedmd.com/IRH for 25% off your implementation fee.

Gabriel Bogner: 

Linkedin: https://www.linkedin.com/in/gabrielbogner/

Facebook: https://www.facebook.com/matefertility/

Interested in adding IVF to your clinical services? Mate Fertility can help with that. https://matefertility.com/how-it-works/

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Transcript

[00:00:53] Griffin Jones: Can non REI, OB GYN provide adequate fertility services, including IVF to the bulk of the infertility population. Right now we talk about that in today's episode, today's shout out is going to go to Lori Whalen, a nurse that many of you know, who's been on the show before and who also connected us for this topic.

So thanks to Laurie. Hope to see you soon and shout out to you. On today's episode, I've got Gabriel Bogner. He comes from the tech space. He comes from the venture space and is building a model in mate fertility that hopes to work with OB GYN in underserved markets to provide. IVF at a quality scale that is much more accessible because it's in these markets that are underserved and either consequently or subsequently more affordable.

So we talk about the inaccessibility in the marketplace as a whole, we talk about Gab personal journey of how he got to. This world, we talk about VC funding and Gabriel. He walks people through. For those of you that are still kind of fuzzy on the difference between private equity and venture. Gab does a good job of sharing what mate has done this far and what they're doing next.

And so I really hope that you enjoy this. I'm not the person that's qualified to say which models work and which ones won't. But I do see the need in the marketplace. I'm glad that that people have are going for it and I will be interested to follow up on the progress. So please enjoy this episode about male fertility with Gabriel Bogner.

Mr. Bogner Gab welcome to Inside Reproductive Health. 

[00:02:51] Gabriel Bogner: Thank you so much for having me. I am super excited to be here, chatting with you all about a mate fertility. 

[00:02:58] Griffin Jones: You made some splashes when you came into the marketplace a couple of years ago, and I'm interested in hearing about that. I want to get your story and why you decided to found this group, but I want maybe start with, tell us about the model of may and what makes it different. And then I'm going to start asking you why and about your story. 

Yeah, definitely. So mate fertility is a really unique business model in the fertility space. And we really focus on three core tenants, which are affordability, accessibility, and quality of care.

And before I kind of dive into what the model is, I'll previsit by saying about eight to 10 years ago. If somebody told you to get in the back of a stranger's car and have them drive you somewhere, you would say you're absolutely crazy. I'm never going to do that and now it's the norm. We do it every single day with Uber.

If somebody told you to go and stay in a stranger's house six years ago, you'd say, I'm not doing that either and now we do it all the time with Airbnb. So it takes a little bit of disruption and uncomfortability to really push the boundary and create new disruptive businesses. And I like to think that's a little bit of what mate fertility is.

And so for our unique business model we're actually an MSO, which means management service organization, similar to a franchise model. And so what made fertility is, is we basically partner with really incredible high quality OB-GYNs in traditionally underserved fertility markets. So we're not going after LA New York, San Francisco, we're going after the cities that are often forgotten about don't get a lot of access.

Don't get a lot of high quality care and we partner with an enable OB GYN in those kinds of secondary and tertiary markets to open a mate fertility clinic and offer full service IVF, fertility care, surrogacy, egg, egg donors, PG TA the whole nine yards. 

So you're a good fit on this show then, because one of the things that we talk about a lot is REI as being the bottleneck to care.

And I'm not qualified to say to what degree the bottleneck should be applied and shouldn't, but we have far more people that need fertility treatment than there are people to treat them at the moment. There's only 1100 REIs in the U S maybe a hundred or so in Canada. And so we're far under serving the populations that need to be served.

You've taken your MSO to work with OB GYN and these underserved markets. And that's another thing that every other show gave, I talk about how there's 44 fellows graduating each year. And they, it seems to me like 80% of them are going to 20 cities or fewer. And it's not, it's not, you know, in general w with obviously exception, but in general, it's not this smaller middle-market interior of the country cities. 

[00:06:06] Gabriel Bogner: Yeah, exactly. I mean, and you hit the nail on the head there there's about 420 to 450 IVF clinics in the entire United States. The vast majority of those IVF clinics are located in top five, top 10 Metro areas with the rates of infertility just dramatically increasing over the past couple of decades, I mean men sperm counts have plummeted over the past 50 years. Women are having kids later on. My couples are having kids later in life. Women are wanting to freeze their eggs. All of this has just led to this dramatic and drastic increase in demand for these services. I mean, approximately 20% of people nowadays are diagnosed with some type of infertility.

That number is even higher when you factor in the LGBTQ community, as well as people who are. you know trying to Basically get out of the genetic diseases in their family. And, you know, some estimate that number to be as high as 30%. And there's just been zero shift in the supply curve. And unfortunately when market economics comes into play and you have a lot of demand and you have not a lot of supply.

You get price gouging and you get prices that are just continually hyped up to ridiculous amounts. And unfortunately the people that are left to pay the price are the patients. 

[00:07:23] Griffin Jones: So, how do you interact with OB GYN in this model or utilize OB GYN who are not board certified REIS in this model, because some, our eyes might be listening thing.

There's no way that they can do what we do. Other people are listening and saying, you know, we've started to do this because we need, and by this, I mean, utilize OB GYN or utilized APPS so talk to us more about how do you utilize OB GYN. 

[00:07:51] Gabriel Bogner: Yeah, well, I don't want to give away all the trade secrets, but I mean OB-GYNs are very skilled doctors and providers, right.

And of course, going through an REI fellowship and being a reproductive endocrinology is extremely well-respected field. And, you know, at the end of the day, we're not trying to, we don't want to step on anybody's toes. You know, we see a world where we work together harmoniously and we're not trying to really tackle the super complicated cases, you know, we like to really go with the running the male infertility cases. And you know, we'd love to work with REI is to take some of the workload off of them. And some of the more simpler, straightforward IVF cases, you know, might say, go to a mate clinic where some of the more complicated cases go to REI, of course, but you know, for when we're working with OB GYN we actually go into their existing clinics and we will up-skill and train them to do IVF and egg retrievals and transfers.

We will actually build them an IVF lab from the ground up in their existing clinics. So. It's almost like a clinic within a clinic. A comparison that I like to make is if you've ever been to a PetSmart and you've seen the Banfield pet hospitals that are in the, the PetSmart locations, very similar where it's a clinic within an existing clinic.

And so those OB-GYNs they are opening a mate fertility clinic under their existing umbrella. They're expanding their services and you're right. We see OB GYN. Getting into this already. They're getting into vaginal rejuvenation, they're getting into liposuction, breast augmentations, varicose vein surgeries.

And so all of this has just led to these OB GYN is really searching for ancillary revenue streams. And you know, also OB GYN is really being able to take care of the whole patient because the first place a patient's going to turn when they're struggling to get pregnant as their OB GYN. And this anyways, they're not necessarily going to go to an REI the first time they struggled, they're going to go to an OB GYN. So imagine the patient experience. They go to that OB GYN that they know and trust, and they've been going through their entire life. And that OB GYN is like, yes, absolutely. I can do IVF. I can treat you all the way through. And so we train those OB-GYNs to do retrievals and transfers.

They go through a very rigorous process through the meat fertility academy. There's also a ton of hands-on training. There's a lot of didactic training. We are training their entire existing staff, but of course we want to make sure that there's quality with everything that we're doing too. And so we don't just kind of leave the OB GYN is train them and say, bye we're done.

Everything is overseen by board certified REI is on the backend. And they are the ones that are really kind of calling the shots on the stimulation management, because that's really where the complicated stuff comes in is, is this dim management and the medication management. And so REI is, are of course overseeing every single aspect of that and really calling the shots just on a virtual basis.

And we're also managing all of the IVF coordination. And so we employed the fertility nurses and they sit on the corporate team. And so there's virtual basically. IVF coordination. Very similar to how a lot of nurses do it today in the international space. 

[00:11:13] Griffin Jones: So you're not going to give away all of your trade secrets here, that's fine. That's what people aren't expecting it though sometimes they might perk up there if they're, if they're hoping that someone does, but at a, at a high level, how, how are you building labs in OB GYN offices, where. Labs have traditionally been very expensive and very involved. And we have one client that just built a brand new center.

And that was a tremendous undertaking was with building this individual's new lab. And so talk to us about what you're bringing to the, yeah, not granular, but at a high level, what is it that you're doing to be able to do that. 

[00:11:53] Gabriel Bogner: Yeah, I mean, well, it's a partnership when we find people that are joining the ma(+)e fertility ecosystem.

So as much as you know, we're trying to sell them on ma(+)e fertility, they also have. to sell us And we have to really ensure that it's the right partner and it's the right location. So we do a ton of upfront work before we go into any partnerships with any OBGYN clinics, offices any other OBGYN NSS, we do a ton of up work on that specific clinic and location to make sure that we would be able to actually build a lab there.

And I think a lot of people love to over-complicate this stuff. And, you know, make it seem like it's the most involved thing in the entire world, but you know, at the end of the day, we've found tremendous partners in the equipment. We found tremendous partners for architecture and build out and we've kind of got it down to a science and we know exactly what type of size what's needed in the labs.

Like what the proper HVAC configuration is. And, you know, we just go in and yeah. And we built them. And I think a lot of people like to over-complicate things and it doesn't really need to be that complicated. I mean, we're getting brand new top of the line equipment on everything too. And you know, we did it, we, we built an IVF fully functioning IVF lab and about six months maybe less than that about five months actually I'm with all brand new state-of-the-art equipment. 

[00:13:29] Griffin Jones: And I remember someone telling me about how all of this was, was possible. If someone else work on an affordable model, not the same, but about how there's this opportunity to. It create labs much more economically and efficiently, but I'll let me play the other side for a second is I can picture someone listening and saying, hang on.

It is really complicated. It is that complicated. And you mentioned that you have your team that trains the OB GYN. They're probably thinking, well, who the heck is training these people. So talk a little bit about your team who is training these folks. 

[00:14:04] Gabriel Bogner: Yeah, absolutely. So we've compiled a really tremendous team of people who have been in the space for upwards of decades.

And, it's really interesting because the beauty of our team is that we have a mixture of people who have been in the fertility space for their entire careers. And then we have a mixture of people who have. Been in the tech and the startup space. And so we both bring these very unique and interesting ideas to frankly, in an antiquated industry.

And so our provider team is made up of four REIs right now. Two of them from Stanford, one of them comes from Harvard. I'm not going to give away any names right now, just because I want to protect everybody's privacy. And then our nursing team is made up of one of our nurses, Lori Wayland, who's been in the space for 20 years. I believe she actually knows you Griffin. And then we actually just brought another nurse. Her name is Stephanie Parker. She's been in this space for about 15 years as well. And then leading up our operations is Tammy, Hickson, Keltner. Been in the fertility space for upwards of about 15 years.

And she ran operations for I believe I forgot the name that she run. HRC. She ran operations for HRC down in SoCal. So we have a really experienced and qualified team. We're not just kind of pulling people out of from the oblique, from out of the oblivion. And we're really making sure that we're partnering and we're bringing on people who understand the mission of what we're trying to do, you know, and at the end of the day, I think there's a lot of companies and maybe even companies in this space that are just trying to do it for the money or because the fertility industry is hot and there's a lot of investors coming in, but, you know, honestly, what we're really trying to do is solve the problem.

I think everybody can admit that there's a problem in this space. And that problem is that there's currently not enough treatment for the amount of demands. There's months, long waiting lists. People can get in to see doctors. And so, you know, ultimately the existing system that is in place today wasn't allowing us to do that. Wasn't allowing people who need care to get access to care. And so what we're really trying to do is increase access and solve this dramatic and huge problem that currently exists in the fertility industry. You know, and we're finding really forward thinking providers and doctors who live and see this every single day in their clinics, see people that can't afford treatment, that can't get in to see them. And they understand the need for just increased access for increased affordability. And you know, we're not, we're really not trying to. Take business away from existing practices or existing REI is, you know, I like to say, we're not trying to steal a piece of the pie.

We're actually trying to make the pie bigger because right now there's a lot of people who just aren't getting treatment.

[00:17:04] Griffin Jones: So a lot of people say that, but I do actually see you having a model that makes the pie bigger. I think it's really important to do, especially in those markets. I want to talk about how you select markets, but I want to talk about how you came to this problem.

You said you're here to solve a problem. You also mentioned there's lots of people coming into this field and many of them with lots of money because they believe that there's more. To be made here. And there is a lot of money going around here, but sometimes it's just shifting from one end to the ship, to the other as, as the waves go up and down.

Right. And I think there's some people here, there are some people that are clearly coming and adding entrepreneurial value to this space. And then there's many people that aren't and I get up in the morning every day and try not to be in the second group. I try to be in the first group.

And even if you have the purest of heart, it's not easy to provide value in business. It's a hard thing to do. We can have an entire podcast episode about that, but talk to me a little bit about why this problem, you're a businessman. You're an entrepreneur. You've been in the tech space.

You've probably seen a thousand problems and What was it about this one that made you say I want to try and tackle this? 

[00:18:16] Gabriel Bogner: Yeah, well relation to the fertility industry goes all the way back to my birth because I'm actually an IVF baby. So it's very full circle getting into this industry and the space for me.

I've always been really fascinated by the fertility space and I remember very clearly. My mom told me I was an obvious baby. My parents were older when they, when they wanted to have me. And so they just struggled to get pregnant. My mom was 38 and my dad was 37 and they just couldn't get pregnant.

And so they went and they, you know, went through treatment and they ended up having me. And so I remember when my mom said that, you know, you're an IVF baby. And I had no idea what that meant, but I knew that I was really fascinated by the industry and I used to run around and tell people I was a test tube baby, and I thought it was super cool.

And as I just delve more into the space that throughout my life, I really began to understand. The intricacies of the industry and what's wrong with it and why it's so inaccessible. It's a multi-pronged reason on why I wanted to go into the space. So that's the first one. The second reason is, know, I have had a long relationship, I guess, with the US healthcare system. As I was diagnosed with Crohn's disease at a pretty young age. And so I had a pretty serious case, ended up having my entire large intestine removed part of my small intestine, I have the J pouch surgery, my J pouch failed.

I actually currently have an ostomy right now. And so I understand just the difficulties of navigating the healthcare system in the United States. I understand. The frustrations that patients go through on a daily basis because I've been living it my entire life. And so I've always wanted to go into the healthcare space, but from the business side to really help and make sure that, you know, the patient experience is better than what I have.

And, you know, although the fertility industry is not Crohn's, it's all the healthcare industry at the end and it's all, you know, patient experience. And of course the patient experiences is super, super important and flawed and broken in the us healthcare system today. And then third reason is I'm also gay.

So being part of the LGBTQ community, Third party reproduction and surrogacy has always been something that's been really top of mind for me, because I've always wanted to have kids, but I never knew how it was going to be possible for me to have kids. And of course, really just understanding the space a little bit more.

You really see how inaccessible. It is for a lot of people in my community. And honestly, how discriminatory a lot of the policies are around LGBTQ fertility care. You know, I think there's a lot of amazing clinics today that have done a really tremendous job in focusing on working with the queer community.

But I think there's, you know, a ton of work to still be done. And we actually just brought on one of our providers. One of our REI is who specifically works with, you know, the LGBTQ community. And so she's really going to be helping us build, build our programming fully out just around, around helping the queer community, especially when we're going after places like Oklahoma, west, Virginia, Kansas, these, these more conservative markets where a lot of fertility clinics and a lot of hospitals are backed by religious organizations. And so, you know, receiving care as a queer individual, as a trans individual, or even as a single woman receiving fertility care at a lot of these hospital back clinics is impossible and we've seen it firsthand in Oklahoma city time and time again. 

[00:21:57] Griffin Jones: So you come into the field from, from an emotional roots of being an IVF baby, having a complicated history with the healthcare system. And being a part of the LGBTQ plus community and seeing a need for family building to be far more expansive than what it is.

How do you get from those three starting pillars to, okay, now we're starting to see a model. Like how did it come down further to like, okay, like, this is drawing me over to look into this area, but then how do you get from looking in to the reproductive health space to this is the need. How did you get there?

[00:22:38] Gabriel Bogner: Yeah, well, it's actually looking out. So instead of looking into the space, it's really looking out what is the rest of the world doing? And you know, this business. A year or two years was really just like researching and understanding the space and really trying to grasp, how can we actually fix this industry?

How can we actually make a dent in the root of the problem, which is there's not enough clinics and there's not enough providers, how can we actually solve the root of the problem? And it took looking outwards to actually come to the solution. So when you look at the United States, 1% of our babies are born using art assisted reproductive treatment.

That number is incredibly low. You look outside Japan, Denmark, Israel, Australia. These countries have upwards of 10 to 15% of their babies being born using assisted reproductive treatment. And of course you ask the question. Why, like, why do all of these countries have so much more access? Why are so many more people using and turning to assisted reproductive treatment, of course, because it's a lot more affordable, but second, because OB-GYNs are actually the ones that are providing the care in these other markets. So they're the ones that are doing the retrievals and transfers. The whole REI kind of full fellowship doesn't necessarily exist in a lot of other countries.

And so OB GYN are often the ones that are doing the retrievals and doing the transfers and doing the stimulation management. And so, you know, looking at just how the rest of the world is doing it and why the United States is so far behind. It's like, why, why, why aren't we doing this here yet? 

[00:24:22] Griffin Jones: So you start from looking out, you're seeing what other places are doing, and you think you might be able to close the gap by taking some pages out of the books of other countries, then how do you start to actually. Build this because yeah, I came in as an outsider. My story is very different from most other people that did come up as an outsider. When people come in as an outsider, they're usually coming in like either as a tech entrepreneur and coming in with some kind of VC backing or they're coming from private equity.

I came as you know, I was a marketer in my twenties and I lived out my twenties traveling. And I knew that I wanted to build a firm and knew that I wanted to subspecialize. And I started working with a couple of clients in this field and decided, okay, I'm just going to dedicate to this field and it wasn't easy.

And some people do a great job at, and some people don't and sometimes it is very much like I had one physician say to me that. He no longer felt this way, but it took him a while to get over people saying our field, as opposed when it's, when it's the physician's field. At least when we're thinking of in very pure purest terms of field of medicine.

And so there's that sentiment. So how did you start to come in to this field, knowing that you're looking outside and as you said, can be insular. What was that like? 

We've been talking about things to expand care and reduce the REI bottleneck. And that always brings up Engaged MD for me. But in unlike the conversation where we're talking about using OB GYN and using other docs in other marketplaces, Engaged MD is a way to scale you to scale your team and to prepare your patients so that your patients have true informed consent so that they have true pre treatment education.

And that you're not having to repeat the same things or that your nurses who are. Over to the bone are, don't have to repeat the same things over and over and get, and instead you use Engaged MD, you reach patients ahead of time. They can watch it on their own time. They can watch it over and over again.

They actually get the module to actually get the education, to actually get the true informed consent so that your staff doesn't need to track everything down for them. And then when they meet with you, when they meet with your staff, you can answer the questions that still remain for them or the parts that they're still hung up on, that they really need your help with because they've gotten the piece that they could get from anybody.

[00:25:55] And now they can get that tailor fit care custom to them from you because you used Engaged MD. If you're not using Engaged MD already, you're in the minority because so many people are using Engaged MD because they say it's the thing that has made the biggest difference in their practice in the last several years, at least many of them have told this to me over and over again. So if you're not in that group, if you are missing out, you can get on the train by going to engagemd.com/irh. If you mentioned that you heard them on Inside Reproductive Health, or you mentioned that you heard them from Griffin Jones, we get 25% off of your implementation fee.

So that couple of bucks off is a reasonable to give you a reason to do it now, but the reason for doing it for your practice is for the improvement to the care that your patients receive, the relationship that they have with you and reducing the burden on your staff. Go to engagedmd.com/irh 

 So how did you start to come in to this field, knowing that you're looking outside and as you said, can be insular. What was that like? 

[00:28:15] Gabriel Bogner: Yeah. I mean in actually like the business it was real. It was really just a matter of like for the first year or so. Just kind of going in stealth mode and understanding, okay, what is needed to actually do this?

Like. What is the training that's needed? Let's build that entire training. You know, what is the continuous management that is needed? How are we going to actually run that? What is the architecture that's needed? What is the lab look like when we're actually, you know, building it? What does, what are the specifics that go into everything?

What does every single piece of equipment that you need in a fertility whap and how do we get all of that? You know, how do we partner with lending services to make sure that we can provide these services to patients that can't necessarily afford it right out of pocket. It was really just understanding and researching and talking to people in the field for a really long time.

And then it was a matter of calling OB-GYNs around the country and trying to find OB-GYNs in the markets that we found attractive to partner with us. And, you know, there was a lot of interest in underst and actually being able to provide this type of care for their patients. And also of course the financial benefits that come along with opening a fertility clinic.

But, you know we talk to OB GYN all the time that say they're referring out 20, 30 patients a week to REI that this is something that is being talked about constantly. And so, you know, we have this initial hypothesis and then in continuing to discuss with people throughout the entire medical field though, OB GYN field, the fertility field, just really beginning to understand, like it just reinforced the hypothesis and continued to tell us that we were on the correct path and that this is something that's actually needed.

I mean, for our OB GYN, I'm giving up a massive portion of their potential revenue because they're not able to treat and take care of any fertility patients. And so, you know, finding really forward-thinking OB GYN that actually want to do this with us. You know, it wasn't as hard as we actually thought it was going to be.

And you know, that it was just a matter of signing that contract and, you know, beginning the implementation process and it wasn't without its difficulties and challenges. And a big part of that was surrounding ourselves with the best team possible. So surrounding ourselves with, you know, a mixture of people in the tech space, people in the fertility, industry, nurses, doctors, operations, people but it was really finding people who understand what the mission is. I think the mission of what we're trying to accomplish is very powerful. You know, finding embryologists. It's a draw to a lot of people in the industry who have seen, you know, this space for decades and have seen just the difficulties that a lot of patients endure. And you know, when we talk about main fertility or really.

A solution to a lot of the problems that exist. And so, you know, just being able to talk about the mission and what we're actually trying to do for the industry has been really powerful. I don't know if that fully answered your question. 

[00:31:45] Griffin Jones: It definitely did with, especially you started talking about this, the staff, and maybe that answers my REI side question definitely answered the question for OB GYN it within that answer, I could see some resistance from REI. So how did you, you said you've got four board certified REI's working for you now and in some fertility nurses, how did you, how did you reach out to them? Because not so much anymore, because everyone's so busy, but even when I first got into the field, there was this concern that OB GYN would be taking.

REI patients and people didn't want that. I think now people are a bit more open to it, but you know, when you're talking about that, like wait REI is taking 20% of OB GYN business. Well, summary summarize might be thinking that OB GYN is now taking 20% of my business. So how did you extend that olive branch or build that, make those headways into the REI is that work for you? 

[00:32:50] Gabriel Bogner: Yeah. Great question. And I started my career as a sales development representative, so I was an SDR. So I was grinding. I was doing a hundred dials a day. I was doing a hundred cold emails a day. I was sending out hundreds of LinkedIn messages a day.

When you start your career, as an SDR or from the bottom, you understand what it means to get creative and how to get people on the phone and get people talking to you. And so literally it was cold outreach. It was sending messages on LinkedIn. It was utilizing people that we had connected with to make warm introduction to the best people that they know it was, you know, utilizing different drug reps, whether they're from EMD Serona to make introductions to various REI s and nurses that they had known who, you know, were looking for something new it's, you know, creating really, really good JDs that actually speak to the person, reading them and making your JD stand out.

And being able to, you know, have a really powerful JD that a lot of people actually want to apply to. I worked at LinkedIn before this, so I kind of understand like the, the recruiting space, maybe a lot more deeply than, than other people will do and how to, you know, send really powerful messages and get people on the phone.

And so that's really what we did. It was just a grind and, you know, once we were able to talk to REI, is that understood the mission? We didn't get, we didn't get pushed back in the way that we thought we were going to. I'm sure we will in the future. And I'm sure a lot of it is yet to come.

But you know, we were very specific or very intentional about who we were reaching out to and who we wanted to connect with. And, you know, once we got those people on the phone, it was just explaining to them what we're trying to do and how we're trying to, to build a better future for the fertility industry and for the patients.

[00:34:43] Griffin Jones: I can appreciate the sweat equity of sales outreach, or cold outreach. I started my career in radio ad sales. So that was the first five years ago, early twenties and mid twenties have a real job. And it was here's the phone book kid, like, and really intense yeah, really high levels of rejection.

But one thing that it taught me was just how to get people's attention and I forget the, what was the acronym you used for the sales rep position that you started? 

[00:35:12] Gabriel Bogner: SDR, sales development representative.

[00:35:14] Griffin Jones: Sales development representative. Okay. So you mentioned that you mentioned LinkedIn, tell us more about your history.

Like how did you get to be an entrepreneur of this company that bridges tech and fertility people are thinking like, who is this guy? So what were the other things that brought you on this career path? 

[00:35:33] Gabriel Bogner: Yeah I went to UC Berkeley, got my business degree. You know, always wanted to go into the medical space.

So I don't think it was a surprise for a lot of people when, I jumped into the medical field. I really wanted to go to a big company before. Went into the start-up space. I always knew I wanted to go into the startup space. I always knew I wanted to start my own company, except I wanted to get an understanding of what it's like to work at a big company before.

And so, you know, joining a company like LinkedIn, doing a rotational program, there really understood what it's like to build a company that has an incredible mission and has a really, really terrific culture like what it means to make people want to come to work every day. You know, what it means to build really incredible cultural tenants, what it means to be a really effective manager, how to effectively manage people, how to effectively have conversations, how to communicate with people, how to sell people on things.

You know, I learned all of this, just working at a different type of working at a tech company. And then you know, just made the jump into, into doing this and it was a lot of connecting with venture capitalists and, you know, VC we're backed by VC money. And so, you know, finding the right angel investors and venture capitalists who believed in this space as well and believed in what we were doing.

But, you know, I'm the first to admit that I don't know everything and you know, maybe I am a little, a little green in the sense that I am on. I am on the younger side except, you know, No one to step aside and let the people who have been doing this for decades and the professionals really take over.

But I can tell you, one thing is that I'm passionate about the space and I am hardworking and I want to make sure that. Patients to come in all aspects of healthcare, have a better experience than, than I did. And to really build a better future. I'm always been interested in like the nonprofit space as well.

So really wanting to build a company that has a really tremendous vision. And you know, I'm not the CEO of may fertility right now we have an incredible CEO. So I'm not the one that's running the day-to-day and calling all the shots. And, you know, I helped build this thing. I understand when it's time to, to bring in professionals and people who have been in this industry for decades to handle a lot of the intricacies that, but I am just not prepared you or haven't done in the past. And that's not to say that I'm not sitting and learning and taking in everything as the other people around me are doing these really complicated things. But you know, I want to make sure. At the same time as I am a leader, I'm also a sponge and I'm also a follower to bringing these people together who know that there's an issue and there's a problem.

And making sure that we kind of have this guiding light into what, what needs to be done, but the actual, how, and the actual specifics and what, you know I'm not the one who's doing the really difficult kind of fertility, heavy lift. 

[00:38:40] Griffin Jones: So talk about how you raised money for this venture, because some of our audience, it comes not just from a financial background, but from a financier background, they're either data to work for VC funds or they're at PE firms. And, but many of our audience are practice owners and most of our audience is practice owners and many of, or younger docs, people coming out of fellowship. And many of them use private equity and venture capital. Interchangeably and they're used to, they're more used to private equity or many of them are because that's mostly who's buying practices that's established money coming in, buying an established business hoping to improve either profitability or efficiency or both, and then sell it at a profit a few years down the line venture being something different. So talk about talk about your background or mates history.

[00:39:39] Gabriel Bogner: Yeah, definitely. Venture is different than private equity. Venture fuels innovation. So if you think about the companies that exist today, we wouldn't have some of the largest and most impressive companies in the world. If it weren't for venture capital money, we wouldn't have Netflix. We wouldn't have Google.

We wouldn't have LinkedIn. We wouldn't have Airbnb. We wouldn't have Uber. We wouldn't have Lyft. We wouldn't have. Pretty much any company that is in your phone today or that you use on a regular basis nowadays, we would not have without venture capital money. And so venture capital basically fuels innovators and fuels people with really great ideas without necessarily having to have a profit from day one.

So they're almost like the engine that starts something. And then. You will often people who don't have their own money or they don't have the resources to do it on their own. And you know, we found a it's it's a lot of just networking. Honestly. It's a lot of reaching out. It's a lot of pitching. It's getting it's literally saying the same pitch over and over again, day after day probably hundreds of times to get 10 people to move on to the next round. You eventually get one, yes, because you know, in a room full of nos, all you need is one, yes. And you know, we were lucky enough to get that yes from a venture capital firm that specifically specializes in seed seed stage companies called strep capitals.

You know, there's different levels. There's the angel round, which is usually smaller from friends and family. And then there's a seed round, which is the very beginning of your business where you're really trying to prove out product market fit. You're really trying to hire the best team.

And you're really trying to show kind of proof of concept down the line. And then there's series A series B series C and eventually there's going public getting bought There's a bunch of different exit options, but, you know, as venture capitalists come in, they are kind of taking a piece of the, the fertility pie, I guess, depending on what route they come in.

So obviously if you're coming in earlier, if you're coming in at a seed stage or a series A they're kind of getting more bang for their buck because it's riskier basically. So a venture capital firm that's investing in a serious. The company, they're not getting as much equity because that business as well established, and it's not as much of a risk.

And so, you know, we found risk-takers and a lot of people have said that it is the most innovative business model that they have heard either ever or in the healthcare space. And so that's what really is getting people interested. And then it's just really proving out what we've been able to do thus far and, you know, utilizing the existing relationships that we've made and, you know, utilizing the existing cause usually there's a lead investor and then there's follow on investors.

So somebody will write one bigger check and then that's kind of. The sign to other investors that might be interested that, okay, this is actually legitimate. I'll put in a little bit of money and then it's utilizing those investors to really. Honestly help you and to be that sounding board throughout your growing pains and growing experiences, and then use that existing network that you've cultivated to raise your next round of funding.

[00:43:08] Griffin Jones: So you did your angel round a cup, you close that out a couple. 

[00:43:12] Gabriel Bogner: Yeah so, we've done an angel round. We did a seed round and then we did basically a CB or like a bridge round. And we are going out to raise our series a actually in the next. Hopefully month or so, we're gonna kick off what they call the road show. 

[00:43:31] Griffin Jones: Lucky. 

[00:43:32] Gabriel Bogner: Yes, very excited,

[00:43:35] Griffin Jones: Well, that's a grind, so I wish you the best with that part of it. How about the marketplace is first off, you know, well, you gave us a general criteria of the markets underserved. But why specifically, why did Oklahoma city become the first? 

[00:43:50] Gabriel Bogner: Yeah. So Oklahoma city is a fascinating market.

There's a Metro population of 1.6 million people. It is one of the fastest growing cities in terms of millennial population growth. In addition to the LGBTQ community the population of the queer community there is rapidly increasing as well. You look at income it's not super high, but it's also not on the, on the complete, lower end of the spectrum.

And we built a kind of proprietary market analysis rubric where we basically have a bunch of different criteria that we put into a spreadsheet and it spits out a grade for us. And, you know, we go after the markets that score, so it's a matter of looking out what are the existing competitors?

What are their ad spends? Are they spending money on ads? Are they doing Google, Google keywords? What is their SEO? Like? What is their other marketing? Like, what are their prices? What's the wait list? All of this has kind of a value on the backend. What's the population growth? There's a ton that goes into it.

And then we get a value out on the other side and we have a really top down approach. So any markets rank in a, for us then we're going after. And we're, list-building specific OB-GYNs, OB GYN aggregators hospital systems. And then we're cold calling. 

[00:45:07] Griffin Jones: When should we expect to see you in other markets? 

[00:45:09] Gabriel Bogner: I would say by 2020. 

[00:45:13] Griffin Jones: So this year. And so talk to us a little bit more about, of just what else you want to see accomplish. What are you paying attention to right now? 

[00:45:24] Gabriel Bogner: Yeah. I think there's a lot of tech to be made in the fertility space.

And so we have a very unique approach, whereas a lot of venture capitalists, you think, oh, they're tech investors or, and a lot of them are unfortunately eliminated a lot of venture capitalists for us, but we're taking approach where let's really get the foundation of our business model.

Let's really make a dent in the market. And then let's build technology around that. Let's build technology around what we see as the need. We're already seeing the EMR space. You know, there's a ton of tech that that could be facilitated from, from that lens. And so, you know, we're, we are always keeping an eye out and kind of making a mental note of what type of technology needs to be built in the space to just facilitate a better patient experience you know, especially services around mental health too, I think is something that we're going to be super interested in. People going through are diagnosed within fertility is that embarrassing that people make is to oncology. It's the same as getting diagnosed with cancer, though, the rates of depression and the rates of anxiety that people experienced.

And there's not enough mental health resources around infertility it's, it's still very taboo. So, you know, breaking down a lot of those barriers and just education for the greater community and the greater public, I think. All the ton of companies out there kind body modern fertility that I've done a really terrific job in educating the population and educating the public about infertility.

And it's a common diagnosis. It's not as scary as you think it is. There are treatments, there are options. These companies have done a really terrific job in cultivating that type of brand and that type of not type of, you know, just information giving and, and we hope to, to do the same to just break down some of those barriers, especially when we're getting into some of the more underserved markets education there is lacking. And then, you know, what we'd love to do is just get to a point where the supply and the demand curve are, are equal, you know, as, as the demand is increasing, the supply should be increasing to you know, we also see a world where we have a mate fertility kind of academy is dotted around the United States where, you know, not only are mate fertility employees going there. Other fertility clinics are sending their nurses there or sending you their, even their doctors or their NPS to just get standard training. Because, you know, as everybody knows in the fertility space, there's a lack of standardization as well from clinic to clinic, could be getting something different.

And so, you know, there's a best practice that people should be following. And so, you know, creating centers of excellence around the United States to just facilitate an all around better standardization of care for everyone. 

[00:48:10] Griffin Jones: What about the idea that, you know, the bottlenecks being REI, but what about the idea of just moving the bottleneck one wrong, further down the bottle that many people would say, well, BG LANs are swamped too.

So are we kicking? This can down three feet and, and if not, why do you think not?

[00:48:36] Gabriel Bogner: I think it's really simple because there's 1000 REIs in the United States and there's 30,000 OB-GYNs. So, you know, it might be kicking it down the wrong, but it's better than what we currently have.

[00:48:51] Griffin Jones: When you were talking about market size and I noticed in the show notes that you had sent over 90 total, correct me if I'm paraphrasing, but 90% of the centers are, or 80% of the centers are in the top 10 metro is that right?

[00:49:09] Gabriel Bogner: Yeah. I mean, so LA New York, San Francisco, Chicago, all these big metropolitan cities, there's an insane amount of clinics in these cities.

And there doesn't need to be any more clinics in these big cities. And, you know, that's why I don't think a lot of people, I guess, listening or see us as competition, really, because we're not trying to go after the cities where there are a ton of fertility clinics, we're not trying to steal market share away from any of these existing clinics.

We're really trying to go after areas where there's, there's just nothing or there's very, very few options and those options aren't great. And so we're really focusing on markets where care does not exist. Places like Alaska, you know, there's not a single IVF center in Alaska. And so that's the market that really gets us excited. That's the market where we want to be. 

[00:50:04] Griffin Jones: You have plans to go to Canada, because as I'm thinking, Canada might have an even worse concentration problem than we do, that probably more than half of the centers are in the GTA or maybe 60% or so of the centers are in Southern Ontario. If you extend Toronto out, maybe like two hours further and there's some provinces that have none.

 Any roadmap for our Canadian listeners? Have you planning on going up there? 

[00:50:31] Gabriel Bogner: Not at the moment, but I absolutely see a world where this goes international a hundred percent. 

[00:50:37] Griffin Jones: Gab how would you want to conclude? Like I said, most of our audience is practice owners, but some are embryologists that might want to come work for you.

Some might be investors that are, it was ears are perking up. Others might be docs that are kind of interested. How would you want to conclude with a mate's vision and what you want to see happen in the market place? 

[00:50:56] Gabriel Bogner: Yeah, I mean, what we really are aiming to do is create a better world, honestly, and create a better world in the fertility space.

I'm sure there's a lot of companies in the space right now that are solving one issue that exists and yes, that issue needs attention. But at the end of the day, it's not solving the root of the problem, which everybody knows exists. There's not enough providers. There's not enough clinics for the amount of care that is demanded in the United States.

And so what we're really trying to do here is actually make a day. In that huge problem by, you know, opening clinics in traditionally underserved markets by having care that is significantly more affordable than some of the legacy clinics and really standardizing and having high quality care at every single corner, by making sure that, you know, we're controlling a lot of those, a lot of those touch points you know, and if you are interested in and you want to learn more about what it's like to, to come join mate fertility then, you know, I definitely recommend reaching out to myself or, you know, just visiting our website. Should I get my email? 

[00:52:10] Griffin Jones: You can give a plug if you want. Yeah. As long as you're not worried about Russian hackers spidering the internet.

[00:52:18] Gabriel Bogner: Maybe I won't give it, but you can find me.

[00:52:20] Griffin Jones: Or people can contact me and I will be happy to put them in touch with you if they don't, if they don't connect with you on Linkedin. 

[00:52:26] Gabriel Bogner: Yeah, definitely. 

I'm active on LinkedIn or you can reach out to Griffin, but you know, we're just trying to just solve a problem that we know exists. And we're hoping that a lot of people see and understand what we're trying to do and support us in doing that.

[00:52:39] Griffin Jones: I wish you the best of luck, Gab Bogner. Thank you so much for coming on Inside Reproductive Health. 

[00:52:43]Gabriel Bogner: Thank you so much for having me.

127: Leadership vs. Delegation in Marketing

On this week of Inside Reproductive Health, Griffin Jones shines a light on what responsibilities should be handled by the principal of an organization and what should be delegated. This is something that all business owners struggle with but is especially unique in the fertility industry due to the nature of being a doctor and a business owner. 

Listen to the full episode to understand: 

• What roles should principals not delegate.

• How involved should the integrator role be in the core operations.

• What do the best brands have in common. 

• When to do a brand refresh

For all the details and visuals go to our blog

126: Increasing REI Productivity with Balance with Dr. Kutluk Oktay

This week on Inside Reproductive Health, Griffin Jones and Dr. Kutluk Oktay go down the rabbit hole on the meaning of work-life balance. They discuss Dr. Oktay’s approach to limiting his patient load to spend more time on research and how that affects his motivation and quality of life. This conversation culminates in tips on how to be more productive and comments on developing leaders in your organization so you can get the balance you deserve. 

Listen to the full episode to hear our perspective on: 

• How to fill your schedule

• What makes good leadership

• How does social media fit into ‘self-care’

• How to approach work-life balance

Dr. Kutluk’s Information: 

Linkedin: https://www.linkedin.com/in/kutluk-oktay-md-phd-909b656a

Website: https://www.fertilitypreservation.org/

Sponsored by: 

Inside Reproductive Health is sponsored by EngagedMD. For technology that educates your patients with true informed consent, visit engagedmd.com/IRH for 25% off your implementation fee.

Mentioned in the Episode: 

Profit First by Mike Michalowicz: https://profitfirstbook.com/

Need help attracting the right people to make your practice great? Connect with us at fertilitybridge.com

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Transcript

[00:00:00] Dr. Kutluk Oktay: I always think that our colleagues thought they were doing the best 25 years ago, but we look at what they've done.

We kind of roll our eyes, right, if we thought that it was today. So I always imagined myself looking at myself 20 years from now.

[00:01:01] Griffin Jones: The episode, I just recorded one a little bit differently than I thought it was going to go. I thought it was going to be about pursuing a career track in academic medicine. And it's a bit of that, but it talk more about what it means to have a meaningful and well-balanced career. My guest for today was Dr. Kutluk Oktay. He's at Yale. He's a professor of OB GYN and reproductive sciences. There is the director of the laboratory of fertility. The preservation and molecular reproduction there, he has published over 200 manuscripts and book chapters. His research has been funded by the NIH for almost 20 years.

And we talk about what it means to have a meaningful career for someone. Not that there's one path for anyone, but giving the listener an idea of what it's like to balance this and how you incorporate different interests, not just in the work part, but all of the things that happen when you're not working, you know, like your family, your health, your fitness, your hobbies, if you have those.

And that's what this episode explores in a way that's a bit more meaningful than just talking about self-care as a platitude, which I can't stand. And then talk a little bit about that in the conversation, but I'll let you decide. So I hope you enjoy.

Dr. Kutluk Oktay, welcome to Inside Reproductive Health. 

[00:02:22] Dr. Kutluk Oktay: Thank you. Thanks for having me. 

[00:02:25] Griffin Jones: I'm interested in the topic that you and I were snowballing, the idea that you had about the ability to have it all as an REI practitioner and specifically with regard to working in an academic setting.

And so before we go into how one is able to have it all, I believe that that the topic you had phrased as was having your cake and eating it too. So let's start before we talk about how to eat the cake, tell us what the cake looks like. 

[00:02:59] Dr. Kutluk Oktay: I'm not sure if there's a cake in this instance, but well, cake is I think hobby, the first trick is that, you know, you need to love what you're doing and if you're doing what you're doing as a job, you know, it's not a cake, right? So it's a cake because it tastes good, then you enjoy it. But even having too much of your favorite food would not be good for you even eventually get sick and tired of it.

So I think to me, cake is what you love doing. And the cake is one that's made with balanced ingredients and not one flavor's overpowering the others and a healthy cake a healthy cake. So you have to bake your own cake. You have to come up with your own recipe. If you have the wrong recipe for your cake you know, you may so soon throw up everything you had eaten so the speak.

[00:03:55] Griffin Jones: We talked about a balance of ingredients. What are some of those ingredients look like? 

[00:04:00] Dr. Kutluk Oktay: Well, you know, a little bit of flour and I'm just getting. 

[00:04:03] Griffin Jones: That's a different show. That's Inside Reproductive cooking. 

[00:04:07] Dr. Kutluk Oktay: I know I just want to make stuff, you know. During the time of COVID we are always disoriented and the wrong show. Okay. Because I do some cooking and that's part of the ingredients, right.

You need to balance your life as much as your work life. And you, we cannot be a single channel or a single ingredient cake. You know, if you just made it the flour, no sugar who's going to eat that cake. Number one is to have their idea of ingredients and not to build on one ingredients.

So maybe if you want to start diverging from the cooking analogy right. In my case, I'm curious, right, because I'm both a scientist and clinician, and I always question, I always question and say, there must be a better way of doing this. And I always think that our colleagues thought they were doing the best 25 years ago, but we look at what they've done.

We kind of roll our eyes, right, if we thought that it was today. So I always imagined myself looking at myself 20 years from now. And first of all, try to always improve things. And so that kind of makes it fun because to me, nothing is routine. Everything is a challenge, the challenge to do better, do better for your patients and do better for the field.

 Never stagnate. And so the ingredients for that reason is of course it's a good patient care, but innovation and always asking, you know, what can I do? What question can I ask? And how do I study that to take this current approach to the next level? 

[00:05:59] Griffin Jones: When you talk about a balance in work life, do you mean balancing life within work with life outside of work, you know, family and hobby balance?

Or do you mean balancing what you do within work? 

[00:06:14] Dr. Kutluk Oktay: Right. So in your life different index funds. One is the work index funds that you want to track the optimum rate of increase in your quality with balancing components of your work. And then you have your family life. Then you have your hobbies and then you have, you know, another balancing there.

And then together you balance all of these together. So you have balancing the compartments, but then you are so the life balance. So when I say work life, not work life, but your life at work. I'm talking about, I personally, if I just saw patients seven days a week, I would probably burn out in two weeks.

And because that's not how my brain functions. Right. And as I said, that, pausing and asking questions, how can I do better? And if you just constantly see patients, you cannot pause and ask that question. So for me action versus introspection in our case, introspection is we could say research because research is introspection to me, you know, asking questions about what you're doing, whether it's right or not.

And how can I just like, how can I be a better person? So for me, there has to be a balance between actually seeing patients doing surgery, administration research teaching, and doing yoga and during your breaks, whatever. If you're doing that to work you have to find the right balance for yourself.

You might be a warrior you know you see patients, seven days a week, I admire you. But I don't have that skill. I personally my approach is I focus on one patient at a time and I put a lot of energy and time in one case. And I probably can do, I don't know, certain number of cases like that in a given time.

And then I turned my energy to more academic questions who would, which would, I answered correctly, benefit those patients or the patients in the next generation. So I have to balance the work like that. And then, and then leave time for things that make you relax outside of the work and that's going to be different for everybody.

But to me family is important. Hobbies are very important, exercise, you know, well, if I don't exercise properly, I could be staring at my screen for five hours and producing nothing. But sometimes you take part in a health to hit that, you know, hard tennis session. And when you come back in three hours, you do work that you would normally do in three days in two to three hours.

So, I mean, time is a very expandable thing. Reality, we think five hours equals five hours. Now, you know, five hours could be 72 hours, or it could be three minutes depending on your mindset productivity energy level. So you have to do things to expand those three hours. Again, to buy your times for other things.

[00:09:22] Griffin Jones: So let's see how many different metaphors we can use on today's episode. I like the index fund. Let's stick with that because you have your total resource allocation in your portfolio. In this case portfolio is the total amount of time and you have a number of different index funds within that portfolio and then with in at specific index fund, you have allocations of shares to different different companies in one index under, or perhaps even across different fields. So let's stick with the work index fund and then we'll, and then we'll move on to the rest of the portfolio. You talked about saying, you know, seeing patients every day, you would burn out within two weeks.

So research helps you be introspective at all. Teaching helps you to improve. Why do you feel that the academic route has been best for you in, in, in serving those different areas? 

[00:10:23] Dr. Kutluk Oktay: Right? I think I have to think about, you know, an artist. Right. You know, why did being a you know, impressionist help me kind of why, you know it's just, I think part of it is you have certain tendencies, 

[00:10:35] Griffin Jones: Let me rephrase that because rather you have your tendencies, why do you feel that working at Yale was more accommodating to your tendencies than maybe if you had gone and worked for a private practice or a network, or maybe if you'd gone somewhere else in the country, why do you feel that working at an academic division suited your tendency better?

[00:10:56] Dr. Kutluk Oktay: I'm not necessarily advocating for or against any company or any setup or private practice and all that. I think you could have a private setting but you could affiliate yourself with an academic Institute and you could still follow by the same index fund so for me. 

[00:11:13] Griffin Jones: Would it be the exact same index fund though?

Or would it be like Fidelity's version of what Vanguard did? Well, you know, it's pretty much the same thing, but the expense ratio is different and there might be some fees that I don't know about. And can you do it the same way? 

[00:11:30] Dr. Kutluk Oktay: I dunno. Yeah, you're right. Their management fees could be different.

And so I, maybe there are different, you know, they may not be as broad based. But I think the key is to think creatively. I think we see examples of these major private enterprises. You know, turning starting fellowships doing you know, academic investments with their private money, et cetera.

So within that, somebody who's interested in boats can also find home. So it's not necessarily, you know, Yale versus some major and right for the private practice, but I think the formula, so in the end, yes, you are right. That not every enterprise would be accommodating right. To somebody who wants to spend time on research.

So first of all, you have to find that study for yourself. But second thing is you may have to create that same for yourself. And you know, if you're attracting research funding one more or the other, or you have some you know, you have some charity or something that's you can attract money and other different ways than you can set up your lab, even in a major commercial enterprise nevertheless in academics it's easier, but it used to be easier. Let's say because academic centers are also facing a lot of financial pressures. So I don't think there's one perfect solution in that sense.

[00:12:53] Griffin Jones: Why do you say used to be easier?

[00:12:56] Dr. Kutluk Oktay: Well, I think if you listen to people for before us and when NIH funding rate was something like 50%, every other grant submitted would be funded and the universities received a lot more government funding, state funding, they had more money to throw around for research and free up there faculty. So those resources have been over time restricted. So with the managed care managed care squeeze as well. So a lot of academic centers you know, they're pushing their faculty to work, you know, similar hours to sometimes, you know, privates centers. And I think in our field it has become a problem and a lot of good any centers have lost their REI divisions and because financially it didn't make sense to a lot of them.

 Must create it Yale in one sense that Yale department of OB GYN and reproductive sciences as always being a pro translational research always support it clinicians with scientific interests and always created time as much as possible or supported them so that they can get funding.

So there's still departments like that somehow, but not as mad as many of those. So I'm lucky to be where I am right now. 

[00:14:16] Griffin Jones: Yeah. Well that changes things for the people that go into work for those places. Don't they, if what they wanted out of an REI division was to spend perhaps less clinical office hours, more research hours if they are starting to see more of the push that, well, we need you at this clinical capacity, no matter what do they lose some of their recruiting edge? 

[00:14:45] Dr. Kutluk Oktay: I think so. I think academic centers especially at the more advanced level you know, junior colleagues, they still, I think are attracted academic centers because they need to pass their boards. Maybe build a little bit of name for themselves, but I think there's a difficulty in recruiting, more senior people and and losing a junior people when eventually they have acquired, you know, certain credentials and skills.

So yes, I think there's a brain drain in academia, especially in our specialty. You know, there are still mechanisms of supporting these like your productive scientist development program wore her, like Yale has this. So we have number of faculty who are on these tracks with protected time.

 And then we see that there are some, you know, rising stars because of that. You had one of our colleagues on your show and there is still opportunities, but you know, if you compare, academia in terms of salaries to a private practice you know, we are all aware of the differences but, you know, I think the medicine, or especially our subspecialty is not something that you want to pursue because you're only interested in the financial aspects.

I think in that case risk benefit ratio is not that great. You really have to love that the path you have chosen. So as I say, somebody who's likes to do a lot of introspection through research will not be happy in that continuous flow of academic clinical practice. 

[00:16:16] Griffin Jones: What advice would you give?

Because a lot of the people that listen to this show are fellows, and some of them might even want to come work for you. So the advice you give could be used against you, you got to remember that, but people are listening across the country. And in other places too, for that matter. And so what, what advice would you give them to investigate if the program they're interested in potentially working for really does meet. What they want in terms of research in terms of protected faculty time, or if it's just kind of a smoke screen, for lack of a better word though. I'd certainly don't mean to say it's so sinister for you're just going to be a workhorse clinician, like you would anywhere else.

What advice would you give fellows for sniffing that out as they determine what program they want to work for? 

[00:17:11] Dr. Kutluk Oktay: So going back to financial and knowledge, I would say invest early, you know, start putting in your 401k. Well, they were early, right? I think that should start when your residents, because if you are number one, you think you are interested in research.

I usually don't like to use term research to speak on cliche whether what it means, I mean so that's why I used introspection analogy, but you're more introspective, inquisitive. You want to approach more creative side of what we do. I mean, clinical creation is also important.

I think I have to start as a resident, maybe even a medical student building that those research skills. And so that, you know, when you hit fellowship, you are maybe a few steps ahead and you can do things and enduring fellowship that could prepare you to be more competitive for an academic job, which would enable you to, you know, get funding early.

And once you secure some funding, then you have more support from these institutions to have more time. So it's a self-fulfilling prophecy, you know, like you start with know to write, to propose, to think eventually you're not going to produce anything. So you have to preempt, I would say, you know, just decide on your career path, not first year of fellowship book.

Oh boy. Maybe when medical school or first year of residency and build those skills and portfolio. If you're interested in clinical research, start working with somebody to build have publications and understand the skills. If you're interested in basic research, same thing and hit the ground running.

And so that's number one. Number two is, you know, there may not be a lot of academic jobs that you can negotiate necessarily about. If the other alternative is working for an academic center and like working for a private practice, but every reduced salary, you may. If they give me this I'll work for academics.

If they don't, then I'll just stick with private practice. I think they need to have a good negotiation. Maybe allow them themselves three years of maybe protected research time in which time they can apply for various mechanisms for junior faculties. As I said, there's a productive scientist development program.

There's the Warhol from NIH and there could be other mechanisms. Most likely they get that on board and then they can build on that. Then start getting, you know, bigger grants, et cetera, if that's what they're interested in. So that would be my general guidance. 

[00:19:51] Griffin Jones: So that negotiation happens for the employment agreement.

This is the amount of protected time. You have this when you're negotiating the employment agreement? 

[00:20:01] Dr. Kutluk Oktay: Right, I mean, you know, some institutions are like, Very rigid, right. And say, okay, you're coming as an assistant professor, unless you get a grant, we'll give you, or, you know, .5 FTE for you to do whatever you want with that time.

Some institutions are more rigid. Some institutions maybe looking for they're missing that we've been talking about portfolios, et cetera. Maybe now let's go more towards smaller. I mean, building a department is like building a national soccer team, you know, like you have to put the people with different skills in different positions to lead, and maybe they have a lot of strong clinicians, but they need somebody who's promising who's going to move the field.

So if you can show them the portfolio like you've done in your residency, you published three key papers. It shows that you are a promising person. Okay. Going back to the investment. So this is a low risk investment for us looks like, but he or she has done during residency. Imagine if you give her time during as an attending faculty, what she could do.

I mean, it's going to depend on the job, but if you have already built some portfolio, it will be easier for you to negotiate.

[00:21:13] Griffin Jones: Okay. So let's move on to a couple of the other index funds in our portfolio. We've talked about what would the actual work-life the allocation of work.

Let's talk about the rest of the allocation of life. You could family as its own index fund. Hobbies would be its own index fund. Health and fitness would probably be its own index fund. And so of those other three things, which, which do you find sharpens the saw most for you? And by that, I mean, gets you back.

You mentioned if you play around a tennis that you can be exceptionally productive afterwards. So which do you find reenergizes you the most quickly?

[00:21:59] Dr. Kutluk Oktay: I don't think anyone matters individually because in the end this is the total amount of assets you retire with. Right. So I don't care which one built that fund.

I think it, again, it's balanced and it's also depends on the day. Right. But you know, I can have the same pleasure as going, picking up my daughter from school, let's say, during the lunchtime and bring her home and chatting whatever, as a you know playing a tennis match and kicking the rear end of a right.

You know, long-time rival in tennis or something like that. I think it also depends on your chemistry that day, too. Right. So so I don't think that there's a formula for one person, but whatever keeps you balanced. But I tried to keep these things going. I agree with you that exercise a regular exercise is important.

I also personally do yoga regularly. I've discovered this maybe three, four years ago. And it's a really, it balances you in some things. Some days you have 10 minutes, you do 10 minutes, some days you have more, you do more. So not only exercising of body at the same time, you're exercising your mind in a different way than when you're reading or doing experiments or seeing patients trying to solve a clinical dilemma.

I think your mind, your brain also needs stretching. So if you only stretch it in one direction, it's deformed. So you know, like seeing patients at stretch stretches this way, we will research stretches this way, but if I do yoga this way, you know, exercise this way, family that way. So you're going to have more space.

So for me, you know, it depending on how things are one may do better on day am. I may do better the other way. 

[00:23:43] Griffin Jones: I didn't think that I would do an Engaged MD sponsorship read for an episode on work-life balance. And then I got to the end of the episode and I'm like, no, this is the meat and potatoes of what you want from someone like Engaged MD. One of my guests and I are talking about the junk bonds of work that go into the work life allocation, the junk bonds are those things that are monotonous tasks that should be done at scale, should be done with software, should be done ahead of time, should be done at the convenience of the user, but aren't. Things like repeating the same information to patients to teach them things that are coming in their protocol.

The same legal forms, except you're tracking down one for this patient. And your staff is basically law clerks because they're tracking it down for another patient. All of these things that should be done at scale, that should be organized in a platform. And that's Engaged MD. That way you're spending your time with the most valuable minutes possible tailoring the experience to the patient's needs.

They know what you're talking about because they're well-educated and you're not acting like a darn paralegal go to engagedmd.com/irh, but only if you want 25% off the implementation fee, if you do, if you go to engagemd.com/irh and you select. You heard them on the show or you heard them from me, you'll get a few bucks off of your implementation fee and it helps us to create more content and give you more resources like this, but you'll also be getting time back to make life better for you, for your staff, for your patients, because that allocation is not infinite.

The junk bonds have to go. And the meaningful work and the meaningful things that we get out of life have to stay, go to engagedmd.com/irh and get some of your time back.

 When you said at the end of the day, it's the fund that helped get you rich was the most important. And in this context where we're talking about rich in life, as opposed to material wealth, but that can be a part of it.

And I think that the question people need to get to this allocation answer is what does it look like at the end of your life? And what, what do you think you'll regret? And I do believe that there are people like Jeff Bezos and like Elon Musk that I don't think they're going to regret, not spending time with their loved ones that much.

 I really believe that those are people that will regret if they haven't gotten to the absolute limit of their pursuit. So I do think that is possible for most of us though. I don't think we're going to look back and say, I wish I worked one more day. I wished that I had taken that meeting.

I wished that I had done that for most of us. I believe that we're going to either regret not having pursued something else that was meaningful or spending more time with our loved ones. But what we will regret if we just sit on the couch and do nothing and we don't, and we don't become better at our craft.

And so now you have more things competing for time. Potentially what I think has to go is the things that don't lead to any one of those things that have been decided as meaningful, meaning candy crush, video games and not to say that all of those things can never be meaningful, but I I'm talking about the things that don't fulfill our, our biggest interest in the form of hobbies that don't make us closer to our family.

That don't make us better at our craft. You know, the YouTube videos that I think those things are the things that have to go and if you want to have a balanced life, you really have to, you have to protect even more. Don't you, in terms of your time allocation. 

[00:27:44] Dr. Kutluk Oktay: Absolutely. You've got to get rid of the junk bonds, you know so penny stocks, whatever exactly.

I mean, I'm not saying I have an ideal situation here. Yeah. As you said, you know, watching TV, you know, Fantastic movies that you can watch and great sports events you can watch. But if you can, if you're consuming a TV three, four hours a day, the social media Instagrams and things like that you know, you're already, what is that time coming from a lot of those other components, right?

As you said if you think that you fulfilled everything else and you still have free time, congratulations to you and you must be in a different dimension, but go ahead and invest your time into other things. Perhaps one of the things that I do is, yeah, I rarely watch TV, for example, I'm never on social media.

I'm very selective. For example, I mainly use LinkedIn, but that's select, maybe I will post once a month. Maybe we'll our operation we'll do an Instagram post once a month. As you said that the social media could be poisonous in that sense. You know, obviously if you have a professional operation, I think this is more for private practices.

 They do all that stuff for you that can spare you, right. In terms of business marketing. 

[00:29:11] Griffin Jones: Well, a lot of people think that I am just ubiquitously pro social media and I approach life as a consumer and a business owner. Not always through the same exact lens. It's important to look through both lenses, but sometimes they are different as a business owner.

I can't get romantic about where my client's attention is. My perspective client's attention, or in the case of providers where their patient's attention is, I have to go where that attention is, and I have to speak to people where they are. But as a consumer, I don't need to be watching what my friends are having for breakfast or some political debate between two people that have no business commenting on policy one way or the other. And I think that has to do with the junk bonds that you were referencing. It's not for me to say this. This is exactly a junk bonds. Although I think generally I could speak to it and generally be right, but it's going to be different for people's allocation, but people do need to get rid of that first, because there's never going to be enough time for all of the other. 

[00:30:19] Dr. Kutluk Oktay: Right, I mean a social media. You're right. There's a business function of it. As I said, you know, you can use that, but otherwise it's designed to be addictive. I mean, it's a drug, so we just, the more we take it, the more you'll be evicted and it's a war text. You'll be socked in there. So, you know I was always scared of that.

[00:30:38] Griffin Jones: Did you think in these terms, when you were building your career outlook, what did you think as you took your first real job? Or did you think, well, this is how I want to build my life. Or did you start thinking about terms like work-life balance after, after your kids started growing up after millennials started talking about it all over the place?

Is this something that a focus that came to you later on? Or did youset out to build your career in a certain way?

[00:31:08] Dr. Kutluk Oktay: I think cliche, right, that's what they say life is what happens to you when you're busy planning. And so obviously, no, but I mean, my goal was always to have fun and that if something is not giving me fun, I'm not saying, you know, fun, meaning you know, I'm going to be playing cards all day or something, but there has to be fun.

Right? So when I followed my own principal, it just naturally happens. I try to do my allocation based on that, but of course, you know, the the more you live and see the more wrong steps and missteps you take, you realize that, oh, you know, I shouldn't have gotten that waste your next time. You're better trained the mouse.

You don't get into that trap. Yeah, I don't think that you can do that allocation at birth. 

[00:31:58] Griffin Jones: Well, maybe that's what we're starting to see more of maybe not at birth, but starting to see it younger and younger. And I wonder if that's the difference when we talk about millennials wanting work-life balance, one of the responses has been, well, all the generations have wanted work-life balance.

It would have been great to have, and surely millennials are not exceptional as humans in the sense that they are the only ones that want balance between their work and their hobbies and their health and their fitness.

[00:32:28] Dr. Kutluk Oktay: Well, I think there expectional, I admire millennials you know, like they're the homodeus.

[00:32:33] Griffin Jones: What's exceptional about them? 

[00:32:36] Dr. Kutluk Oktay: They've got all the skills, you know, like we didn't grow up with a giant life pop med, you know, the internet, right. We came into that. So they have this huge life, bob mitt on internet. They can, they can get their answers to everything. I mean, one question is now, how necessary is the classical schooling system?

And you know, you can get all the information. Of course, the skill we need to teach them is to objectively analyze what they see on the internet to scrutinize it. But my 15 year old has more wisdom than I had when I was at 35, because of all the giant global library that they have at their disposal.

 So they figure it out. When I figured it out at 35, they figured out that 15, of course they don't, you know, like, why am I going to be a doctor? I want something that offers me more balanced. I'm going to plan something so I can work from home or, you know I'm going to boost start-up I don't want to work for anybody else.

So I think that's where I'm saying that they have that kind of long view. They don't have the classic on the standing of her going to working for somebody it's still the right. Of course that's going to create some kind of anxiety in that generation because you know, there's so much competition for the independent space.

So it's an interesting experiment and I'm waiting to see how it's going to end. You know, like I lived there 15, 20 years, we'll figure it out. 

[00:33:57] Griffin Jones: So I think that's what makes them accept. It's not the desire to, because you yourself have talked about that desire, but it is exceptional that they are coming into the work force with a picture in mind of what work-life balance looks like.

And they are willing to prioritize it in terms of walking away from offers or quitting jobs or who they go to work for. And your point is interesting about how the accelerated learning from the digital age has been a part of the accelerated expectations, right. You hit on the accelerated learning what you knew at 35, your 15 year old knows.

I think that's all also true for expectations of, oh, if this is what a 35 year-old drives and what a 35 year old makes in salary. And this is what I want coming out of college too. 

[00:34:53] Dr. Kutluk Oktay: You know, I don't know if it's some kind of enumeration issue, but definitely they have I think you know, more global view on things and the priorities.

And so, you know, maybe you know, maybe they don't think that you need to sacrifice your life because life is the most, you know, most valuable commodity. To you know, have a luxury car, right. And I think they're so globally connected. They experienced the word globally and you know, they have other ways of enjoying life rather than traveling on a private jet.

So you know, it's not a hippie generation, right. But I look at it as you know, differently, less militaristic male generation. I don't know how I put it, but that they're less regimented to me more broad minded. And they don't want to be you know, put into cubicles to achieve what they want to achieve.

And I don't think there's any amount of money that can force them into the lifestyle that they detests. They think they have options, let's say.

[00:35:54] Griffin Jones: Well, I think one wrench in the works is that having junk bonds in the portfolio, I think they want the yield of the portfolio. And that is, it is possible to get a high yield from portfolio.

But I think that there's a lot of junk bonds in there. And that's one of the concerns that I have when I hear the word self-care and I hear it's, I am more than open to the idea of self-care it is necessary for being productive. If it's something that, that actually helps rejuvenate you, that if it actually helps you pursue a larger goal, but if it's just increasing media consumption or if it's just an excuse to differ from an obligation, then I don't see how we get to a place where we have 30 hour productive work weeks. If there are marbled with escapism. 

[00:36:54] Dr. Kutluk Oktay: Right. Escapism it's the right word. I mean, that's why it's a drug, right, alcohol, drugs, social media. You're constantly escaping from what you have to do or what you should really be thinking.

 That's kind of what the quick send for the next generation. So that's going to engulf some, some talents and bog them down but others will learn how to dance around it and hopefully do great things. And I think also being aware of what we are doing to environment is also very a lot of young generations are aware of that. And a lot of them are more worried about that then you know, filling up their coffers because you know what good it does if you don't have a good healthy planet to live with, what are you going to do with all that money? So I think that's the other reason, I think this generation will have a long view because they need to think about the entire planet with what they do. 

[00:37:54] Griffin Jones: Well, \ they do have a lot more to think about in terms of, you know, having to have a response for other things that are, that are happening. And so let's pretend that we, we have solved for the junk bond issue for the moment that we've gotten all the junk bonds out of our allocation.

We are left with high yield, low cost index funds that lead us to a good outcome. At the end of all this. But then there is this pestering concept that I hear from, and about physicians who look and I don't know that it's erroneous. It could very well be valid, but the, but the idea is that, well, physicians can never really be off.

They can never be totally unplugged because what if our patients need something from us.

[00:38:45] Dr. Kutluk Oktay: Well, I have to take a break now, so I'll see you in five minutes just getting right. I get to a point physicians can be off on the paper, but they can never be off here. Because I mean, at least personally, but I know a lot of other people, you know, and if we wouldn't, if I go away.

 I think about my patients. What happened to this? What happened to that? What happened to that? That's the nature of it. That's why you don't pick this field. If you're really not, you know, you don't like to have that kind of lifestyle. Right. But not necessarily your uncle, every movement of today, but when we are caring for people's future it's hard to completely detach yourself from that.

But if you're working in a good team situation and you have colleagues that you can trust maybe you can disconnect nicely when you're off, when you're doing your yoga, when you're like a week away with you know, doing the things you like. But if you're a one man show, yeah, that's very hard.

Maybe one of the advantages of being an academic sort of larger practice is that you can have other people take the burden off of you sometimes. 

[00:39:53] Griffin Jones: Can you do that if you're taking a two week vacation with your family and you just want to be alone with your family and a cabin in Europe, can you say I'm not taking any calls?

I trust my partners to be able to handle the case. Can a physician do that? 

[00:40:12] Dr. Kutluk Oktay: I can imagine a physician can do that. So I'm I can imagine that it happens in other practices. All I could say that, you know, academics and other places, I've been to several places and I've seen that happen. I don't necessarily see anything wrong.

That's an individual personality issue, I think And you can also set limits. I mean, I don't need to know these, but if something like this happened, yes, you can contact me. You know, we have patients that we make very personal personal relationships in terms of patient doctor relationships and that sometimes they just want to hear from you.

And so yeah, there will be situations, well you could be in on vacation, but there's some emergency, we'll have to answer that. But the key to that is to be able to switch on and switch off you make a phone call, you know, give instructions, and now you're back to as if it's never happened so it's matter of a.

[00:41:05] Griffin Jones: What about the doctors that say, I trust my partners, they're perfectly qualified, but my patients expect me and they have to be able to reach me. And I can never have a window where I'm unreachable. 

[00:41:20] Dr. Kutluk Oktay: Right. If you're complaining about that, that means that you need to change it. So you cannot say that I don't trust my colleagues.

I need to be reachable, but I'm never off. So that's like trying to have the cake and eat it right. Going back to that. But when it comes to patient care and when you're trying to be personal with your patient, provide personal, there's no formula for that other than cloning yourself. So either you trust your team or be available.

So I don't know if there's a formula for that. So I, for me, I set sort of criteria. Okay. You know, XYZ happens. Perfect. Good. Go ahead and map. But it hits, I dunno, let me cry. Then you have to call me and you know, that way, if you get a call, you know, that it was absolutely necessary or, you know, you clone yourself, there's exactly a personal like you and a fine great, go away to Mars on a mission or whatever.

Nobody can reach you. 

[00:42:21] Griffin Jones: I have somewhat of a formula. It doesn't totally address the limits that you would set in terms of, of what you can use of what people can contact you for or not. But it does give a formula for how much time one might want to protect. Have you ever heard of the book profit first? 

[00:42:41] Dr. Kutluk Oktay: Maybe I'm not sure.

[00:42:42] Griffin Jones: Well, link to it in the show notes. The author's last name. I can't pronounce, even if I remembered it, but it's the concept is a bit contrary to gap, generally accepted accounting principles, where revenue minus operating expenses equals profit and profit. First, it simply is revenue minus profit equals operating expenses.

So you're always allocating for profit, even from the infancy of a business. And if you're an infant business, you, you have almost nothing to allocate anyway. So, but you start with that current allocation percentage, and then you have a target allocation percentage. And so in the beginning, you might be saving a dollar, but the point is that you reserve profit from the very beginning and learn to manage operating expenses accordingly, as opposed to the reverse. And when I think of the needs that we have to have loving relationships with our families to have mental health and clarity breaks, there has to be some time and I'm not going to tell people how much time it is.

 But when I'm with my loved ones, that there's nothing that's going to interrupt that unless it is a grave emergency. And so I'm going to write this book someday, Kutluk called time first, where it, you start off with a current allocation percentage and maybe it's just, you know what, every Sunday evening, I'm gonna I'm tucking my daughter in, and I'm going to read her a book and nothing will threaten that.

And then a year from now, I want to be able to do this and five years from now, I want to be able to take three weeks in Europe. I believe that that has to happen. People have to have some allocation of percentage of uninterruptible time and then based on how that goes and how much they want, then they can have a different target to augment for the future.

[00:44:32] Dr. Kutluk Oktay: Right, I mean, you know, the vacation break, whatever is break, but I also think about you may have that time, but there is a situation. If you didn't respond that would create consequences that cost you more time in the future, which would come out of your family time. So even when you're on your off time, you have to be able to recognize the situation.

If you didn't respond at that time. That will cost you a lot more time in the future. So you can think about scenarios of, you know, the complication happens and you, you don't give the right instructions or whatever that, you know, them medications may take more time. So it's a bit tricky. We say that, but you know, as a physician as I said, you need to be able to have some kind of artificial intelligence in your system that will read that out.

Do that calculation for you before you're interrupted. It doesn't happen a lot if you have a good team. So that comes to building good teams. You good leaders are the ones who develop other leaders. Your leadership is measured by the index. Of how many leaders you can develop or how many people who would lead others.

But when you're building your team, you need to build people who can also independently think and function with you. Again, if you don't have a good team it's hard to have time off. 

[00:45:57] Griffin Jones: Well, in order to have an independent team, though, you also have to take some time off because how do you know if they're really independent or not?

If you're constantly there, they will ask you and you will stick your finger in the pudding jar. If, if that temptation is offered, I took two weeks last year in 2021. And my team didn't make every decision that I would have agreed with. It revealed to me. Oh, there's, there's one to three things here that are clearly missing from our core processes that I need to fix.

And I only knew that because I went away and they made a different decision that I wouldn't have made. and because of that, it's like, okay, well, I was gone for two weeks that the farm isn't going to burn down the practice, isn't going to burn down during a two-week period. But then I can make the, it could, I guess it could. 

Well, that's a good, that is a good point though, because I couldn't have done that six years ago, so that is a good point.

 But that's why you start with a day and then maybe it's a couple of days and then it's two weeks. And eventually I'd like to be able to go for big blocks at a time. So we've talked a lot about the different balances of work, not just what goes into work, but also the things that accompany it like health and fitness, family and hobby.

We're going to conclude the show and a lot of private practice owners listen, but there are a lot of division chiefs that listen to this show. And one of our biggest segments is fellows and it's younger associates that are thinking about what the next move next move is. So how would you want to conclude with them, Dr. Oktay? 

[00:47:34] Dr. Kutluk Oktay: Well, to fellows are the biggest, you know, very important part of the team, whether they're clinical fellows, research fellows, you know, observers, whatnot. And in my career, I always worked with fellows of again, either clinical fellows or fellows from various parts of the world.

 And their contributions are tremendous. So they are important part of the. And that's, you know, by working with a mentor prepares them well for the future. So my advice to them again, I said, you're a fellow now, but if you are planning to be a fellow, you're going to start early bit, but also find yourself a good mentor and which could help you with whatever you want to accomplish in your career and work with them. 

[00:48:18] Griffin Jones: And you said that you are active on LinkedIn, so that may have been a little subliminal nod if somebody can people reach out to you on LinkedIn, if they're interested in it.. 

[00:48:27] Dr. Kutluk Oktay: Oh yeah, absolutely.

All the time. So, you know, I decided to focus on one social media gadget. And I think LinkedIn works well because it's nicely filtered and more focused on professional topics and I think it's pretty efficient.

You know, I have through LinkedIn may have formed many alliances, solved many issues reached out to executives of insurance companies when we had problems with the patients, reimbursements, things like that. So I think LinkedIn is a really a good way to expand your network. 

[00:49:02] Griffin Jones: Well, before I let you go, I know that everybody listening to the audio and not watching the video is picturing you as a millennial with your artists in coffee and your beanie and a flannel, but Dr. Oktay is in a suit and tie today, and it's been a pleasure having you on Inside Reproductive Health. Thank you Dr. Kutluk Oktay for coming to IRH. 

[00:49:22] Dr. Kutluk Oktay: Thank you. Thank you. Next time, I'll put that digital outfit on. 

[00:49:27] Griffin Jones: Sounds great.