In this episode, Griffin talks to Valerie Libby, a second year reproductive endocrinology and infertility fellow at UH Cleveland Medical Center. They discuss what millennial REI fellows want in the process of building their careers, such as mentors, work-life balance, and more business training, and analyze how the risk-averse nature of the medical field and an outdated business model keep fertility doctors from opening their own practices.

G: Valerie Libby is a current reproductive endocrinology and infertility fellow at UH Cleveland Medical Center. Second year fellow?

V: Hm mm. Yes.

G: Valerie is also an advocate for egg freezing and women taking control of their future, having frozen her own eggs four times, including fairly recently.

V: That is true. Yes.

G: Today, Valerie and I are going to discuss the topic of what fellows really want as the process to become an REI is certainly a long, fun, and challenging one. Dr. Libby, welcome to the show.

V: Thank you for having me. I’m excited to be here.

G: I’m really excited about this. And I want to start with the way--because I think it’s relevant to the conversation, you’ll see where I go with this segue--do you recall how you and I met?

V: Yes. I, I believe that it was at PCRS this year, and I had seen your Instagram account, I think. And I, I remember seeing you in person and recognizing you, I think. And just wanting to get to know you because I also really like social media. I mean, I think social media in this field is very relevant, considering that our patient population is very much entrenched in social media, so I, I was very excited to meet you. I think that’s how we met. Correct?

G: It is how we met. You were with a flock of fellows at PCRS and you recognized me from social media and you said “Hey, how come you don’t come over and talk to us and, you know, introduce yourself, and I was thinking, like, because the fellows, at PCRS especially, are like put on a pedestal. PCRS is like, almost like the fellows showcase. And so I thought it was super relevant because some people don’t love that. Some people think that we make too much of a fuss over the fellows in our field and part of the reason this topic came about was because, because there’s a differing view of the people coming out of fellowship right now from those that are getting closer to retire and did their fellowship about 25 years ago. So do you think we make too much fuss over fellows?

V: I mean, that’s interesting that you say that because I had no idea that that was the perspective that you and other people may have with regards to PCRS and fellows and you know, we don’t, we don’t--I at least don’t feel that way. I feel that if sometimes I feel like we don’t make enough of a fuss about the fellows, you know. But I think that, we, I guess we don’t appreciate the amount of effort that goes into, that people, put into conferences like this, you know, into the fellows. Do we, looking back now in retrospect, we have so many wonderful opportunities at PCRS and many conferences throughout the year that we, you know, people really invest in our future. We appreciate that and I don’t think we realize that we were put on this pedestal because, you know, we try to, you know, we’re still at the bottom of the totem pole, you know. We had to work our way, way way up back when we were medical students and had no idea what was going on, trying to please everyone including the, you know, all the nurses, which we still do. But, so I feel like we are sometimes thought of as on pedestals but I, I think that we appreciate, you know, people investing time into us.

G: I think it’s supply and demand. I think we put MBA players on the pedestal because not that many people can jump over Steph Curry And dunk the ball in the paint. I mean that when there are only 1100 board certified fertility doctors in the country and there’s this many jobs, and only a sliver of those that can be filled by those qualified applicants coming out of fellowship, I think it’s just supply and demand. So, and I have my own, you know, views about, about millennials entering the workforce and sort of the view on taking over practices--we’ll segue more into that--but now you and I, I think, we both graduated high school ‘03…

V: Yeah!

G: So we’re among the older millennials. I think that puts us, you know, in the mid ‘80s, I think. Most people are defining millennials as about ‘83 as more or less when the generation starts. That means that the oldest of us now are in our mid-thirties, which means the oldest of us are doing things like owning marketing agencies and starting to take over practice management AND come out of REI fellowship. This being the case, do you think that the new REis coming out, maybe having done some traveling maybe having had a cool life in between summers and college, do you think that today’s new REI class puts too much emphasis on the life part on work/life balance?

V: Okay, so you’re saying do I think today’s REIs are not having those life experiences or they are having those life experiences?

G: I think the criticism is they’re totally having those life experiences and that it’s more about that than being accessible to a patient at 2:00 in the morning or being able to work long hours. The criticism that I often hear is that today, the younger REIs want to come in, punch a clock, and go home.

V: Yeah. I mean, I, I can’t really speak to that perspective because as I’m only 33. I do know that as, you know, every generation says that the generation before them did not work as hard and don’t work as hard and the thing is that we are the product, like you say in your blog, of the new, of so many things in the environment that didn’t exist, you know, decades ago. And, I think that, I personally do think that, like, I’m a little bit older than some of my peers, but, you know, a lot, a lot of people are still just going straight from college into medical school and don’t have some extra life experiences, and they’ve worked really hard to get where they are, and they continue to work extremely hard. That’s been mostly the case of people that I’ve met, at least going into this far into REI fellowship. I think it really makes you unique and relatable if you have life experiences. As far as like being the type of people who wake up at 2 AM and stay at work till 10 PM, I also think it makes us more relatable if we go home to a family, which I don’t necessarily have, but if we, you know, if we go through everything, if we, you know, do things to make, to make, you know, to help our patients understand that we understand what they’re going through, what their desires are. But I think that being an REI is, is, is an honor but also it’s not, not very hard once you get here. From what the attendings that I’ve talked to have said, it, you know, they say that it takes a lot to get to where you are, but once you’ve finally made it it’s really not that hard. You really rely on your staff, your nurses, your practice manager, you know, all those other people, to help make you successful, and I feel like, you know, I do think that, you know, the doctors that go really above and beyond and stay at work extremely late and sacrifice many things in their life, you know, on a daily basis, are exceptional people, but I don’t think that’s, you know, I think there’s a way to balance your work and your life. And I think that if you can do that, you’re, in my opinion, even more of an exceptional person.

G: You’re second year, right?

V: Yeah.

G: Are you already being courted by potential employers?

V: I mean, I wouldn’t know if you’d call it courted, but I’m talking to a lot of people, yes.

G: What are you looking for in a--because I’m worried. The title of this episode is What Fellows Really want, and I’m just more interested in an anthropological case study of you, which is just like what are you personally looking for?

V: Yeah.

G: What, what, when you meet someone do you feel like this is a good fit?

V: I mean, when you, when you first start looking for jobs, you really have no idea what you’re looking for. It’s, I mean, it’s hard even when as a medical student you’re choosing what specialty you’re going in because you really don’t know what life is going to be like for you when you, you know, end up rolling into that job every day. So you don’t really know what you’re looking for. But as I’ve done this process, you know, I’ve been on this trail for a couple of months now, I kind of know a little bit more of what I’m looking for. And I don’t know if this is necessarily true for everybody, you know some people may really want academic physicians, some people really want to do a lot of research. Some people want to, you know, go to work at, you know, get in at eight o’clock and leave at, you know, four o’clock and leave everything at home and not having any other responsibilities, and I respect that too. But everybody, you know, wants different things. For me I think what’s important is, is having transparency and having a clear, like, being able to have a clear understanding of what the current physicians in the practice, if, if you’re planning on joining a practice, what they expect of you and what, and what goals you need to meet in order to, you know, reach certain milestones like maybe it’s partnership or what does that mean as being partner? Does that mean share in the company? You know, what kind of, what does that mean and what it takes to get there and understanding, you know, everything with regards to the contracting, nothing being, you know, elusive. Everything being very clear. There’s a clear non compete or there is no non-compete or whatever there is. I think transparency is important as well as does being feeling as you’re in a collaborative environment where the success of others in your practice is dependent on your success and your success is dependent on others so everyone feels like they’re kind of working together. I really think that that’s an ideal working environment. You want to feel like you have, coming out of fellowship is very intimidating and can be--yeah, it’s very intimidating process. You’ve been studying in the books for the past 10, you know, 20 years, like your entire life. A lot of people don’t have those MBAs or, you know, the marketing experience, and really, they don’t understand the environment that they’re walking into and that it’s a, sort of a, you were saying on your blog a corporate environment. And to be able to survive in this field you need to have good mentors I think, whether they are business people, but, also obviously doctors, you know, helping you. You may have, usually as a fellow you are training in an academic environment so you don’t have the private practice experience. You don’t know how a business is run and you don’t know how to work within that experience. I also think opportunities for growth are important, so, you know, if your niche is oncofertility or if it is freezing eggs or whatever it is, if you want to, you know, really focus on that, I think that a really good mentor and good partners will help you foster that niche that you want to explore. And then, I think that it’s important to find a practice that has good values, and an environment that has good values and integrity and puts the patients first. First and foremost in this business, we have to remember the most important thing is our patients. And then finally, you want your partners or your practice environment to be respectful of your personal life, whatever it may be that you are, you know, that you put as your priority. You know, obviously work is typically our priority, but things may come up and being able to work together is important.

G: There’s like three different rabbit holes that I want to go down that I’ll pick one, which one thing that you said about transparency which probably could be an entirely different show topic. But…

V: Yeah.

G: But, the blog article that you are referencing of mine is that, I wrote an article called--that would, it’s part of a four-part series, but the headline that really got people to click it, I almost used it deliberately as clickbait was, the email was “Are REI Fellows Entitled?” I think that I got more clicks on that email than just about any other email that I’ve sent this year because…

V: Wow.

G: ...people wanted to opine, people wanted to check it out. And I did that deliberately. I knew that it would, it would get people going. But the criticism is often that, is that REIs don’t want to, new REIs don’t want to set up their own practices, they don’t want to take over and get out within four years of retirement or so. And I think, what I’m seeing, a bit more of what you’re describing is that need for transparency and a bit more caution because I’m seeing often relationships break up that the associate comes on board, they’re thinking one thing and the retiring partner has something different in mind. And I don’t know where that breakdown in communication is exactly but I know that those expectations are different. So I’ve seen multiple times this year, an associate not necessarily out of fellowship but usually younger , maybe late ‘30s been in the field for a few years break apart from the practice that they were supposed to become a, a partner with because there’s some sort of expectation that’s not being met. And so the argument that I make in my blog post is that the, the REI practice we’re modeled on right now is just an inherited model from the healthcare practice, the small independently owned clinic that is, is from the mid-twentieth century. And now what we’re seeing is a huge influx of corporate money, of, now there’s digital marketing, there’s so many other things that involve owning a business in this field that is much different than just owning a healthcare clinic. And I think people coming out of fellowships see that and they see the risks associated with that and I don’t think that the people that are, are closer to retirement saw those same risks and I don’t think that they’re considering them now either. I’m very curious, like what are people now saying in, you know, your cohort about starting their own practice? Is that something that people still have the appetite for?

V: You know, like you said, I think the environment has really been changing so it seems like not only do we not know what it looks like or what it will look like in 10 years, but neither do the people who are going to retire. So, I mean, my, my father, for example, owns a private practice in neurology and he has two sons going into neurology. So he really cares about what it’s going to look like in 15 years when he’s retired and he’s building these practices for his sons, you know, or of course, maybe. Hopefully. So, I, I think that you can find mentors out there that care and want to know how to be? That and look out for me and try to, you know, guess what the world is going to look like in 10 or 15 years. And people are saying so many different things, you know. People really don’t know, even the smartest people who are going to retire or whatever. But so as a new field, as far as our fellows, do they have the appetite to start a new practice? So from my experience, the current, my cohort of friends, nobody’s really talked about starting their own practice and, you know, as unfortunate as that may sound, it’s also a product of the fact that we have been working for so long to get here and we kind of just want to start making money and start, you know, working and seeing patients and you know when you walk into a practice that’s already created, you have patients there. You can, you know, have a salary, whatever it is that you want. So that’s one reason. And then also, because no one’s really, that I know, really, you know, started completely on their own, people have started branches of other larger corporations, which is amazing and also not that common. As a new fellow that’s very hard to do because, you come out of this academic training environment, you don’t know what a private practice looks like. But at least you’re under the umbrella of a larger corporation that can provide you the resources that you may need to start that practice, and the experience from the other practices that they have. So to start on your own, is just, you know, very, very scary for us, and we just want, we don’t want, like, we, we have been training in this environment where, you know, don’t ruffle any feathers just kind of get through, keep your head down, and, you know, complete what you’re supposed to complete, and you know, risk taking is not something that we want to do when it comes to patient care. So when, when we’re talking about business, the business world, which we have no, usually have no experience in, risk taking is something that we kind of are averse, we, you know, we want to, you know, do, but, but mostly because we’ve trained in this environment where risk taking is dangerous, you know, for patients.

G: And it’s a huge risk to start a business. I started a business but I didn’t have any debt. Also, as a digital marketing agency, there’s not a ton of inventory to put up capital against to have that risk there. And it’s still a huge risk, and it’s still, you know, can weigh on you— to your point, you know, it’s not like there’s a lot, a lot of training that you have. By nature, physicians should be risk averse to a degree, you should be following best practice, and this intense training. Contrasting that with the entrepreneurial free market, which is all about test and reiterate and in terms of the competitive landscape is 100% about ruffling feathers.

V: Yeah.

G: So you mention that, listen we don’t have any MBAs. I’ve talked to some of my friends like Dr. Dan Niode in Toronto who’s a young REI who often says there should be a lot more business training for physicians in fellowship, or at least some. Have you had any sort of business training along the way, whether residency fellowship, medical school, that wasn’t part of a separate program but was part of those trainings? What is the business training like today?

V: Oh my gosh, I mean. It’s really not existent. I think that, you know, the conferences that the REI fellows go to every other year in Park City, Utah, are in my experience, the only business thing that I’ve ever gone to. Unfortunately. I love business, but, but I focus on learning how to be the doctor and that’s what most of us have been doing because it’s so hard to learn to be a good doctor. But when we were at this conference, when we go to this conference in Park City, one of these heads of these corporations who’s also a physician came to talk to us about--Dr. Richard Scott--he came to talk to us about, you know, the, sort of the environment going into private practice versus academics. And then we had Dr. Francisco Aridondo talk to us about marketing. But they were both just one hour lectures--really great lectures--but I mean, it’s hard to really, you know, take those tools and apply them when it’s only one hour and that’s all, you know. So I, I think that some people don’t care about the business of medicine, and I think that’s okay, you know, because they’re going to be great doctors anyways. But, and their goal may be solely to take care of patients.

G: Well, I completely agree that some people say, “I just want to practice medicine and I don’t want to get involved in business.” I don’t want to pay my taxes either, but I still have to. So I think there is a degree of not all of us are called to be entrepreneurial or to own a business, but there is a certain degree of literacy that’s really important because even, let’s say, even if you go into academic practice, there are some of the systems, or, excuse me, some of the hospital systems or of university systems are being bought by private equity firms. At some point, somebody has to make a decision. Is it, how am I benefitting from this, what is my stake in it. There’s a degree of literacy whether if you want to be a full on entrepreneur and start the next largest clinic in your area, then I think that literacy is really high. But I think even if you want to go into academic institution that there’s a certain degree of proficiency that is well-serving.

V: Yeah, I mean, I do, I do agree. There is a certain level of understanding that you need to have in order to, to, you know, to not, like, do well, to do okay. But, you know, how, how to incorporate that training I really don’t know because we really, you know, do need to focus a lot of our time on being, you know, becoming good physicians. Maybe, I mean, during fellowship, you know, we usually have two, one and a half to two years, of just research, and during that time, you know, other than studying for our oral boards, we have a lot of time to go to conferences and things like that, and I think that during that time, having, you know, an optional, you know, business and REI conference would be a great idea. That’s something I’d like to go to. But, but you know, it’s hard because you know whoever puts on these conferences, you know, usually large corporations, aren’t going to want to be a part of it because it might, maybe they will. You have to, you have to figure out if it’s, you have to balance between, you know--well actually…

G: I think that goes back to the, back to the pedestal. I think that everybody wants access to you all. So I think—

V: Yeah that’s true.

G: I think these corporations would be happy to come in and do a, either do a training or I think what you really have to be vigilant about the opposite end of it, which is making sure that either multiple people have opportunity or that one company isn’t getting unfair access because of a conflict of interest. But I think, I think a lot of people would love access to…

V: Yeah.

G:...access to fellows. To your point about mentorship, which I think, I think is valuable in any line of work, especially entrepreneurship: what most, what I hear very often docs who would like to retire in the next five years say is I would love for somebody to come on, me mentor them for five years, and take over the practice. I think that some of that risk that we talked about that a lot of docs coming out of fellowship aren’t clear on that, but when you think of your peers when they’re saying Okay I could take the opportunity and go for this bigger practice that is, you know, I sign on, there’s probably a legalized partnership track that’s in place. They’ve got a big share owned by private equity and maybe by more than one firm versus this single doc practice and this doctor would like to retire in four and a half years and I want to take over. Is there, is there even any palate--we talked about how there isn’t much palate, not much appetite for starting one’s own practice. Do you even hear much appetite for taking over a single physician’s practice?

V: What I have appetite for is maybe not what everybody else does, okay. So I’m speaking on behalf of what I think, what I’ve heard. I love all the entrepreneurial stuff, and I love the idea of, you know, although it’s intimidating to think of starting on your own. Is that super scary? Absolutely. Do other people in my field at this point willing to take on this risk? No. Probably not. I don’t, I haven’t really heard of other fellows— usually they’re thinking, you know, they’re, they’re being recruited by these big, I guess, venture capitalist companies or doctor-owned companies that have a clear path to partnership, that are very large you know, those types of things. They’re usually being approached by those people and they are, you know, it’s an easy and safe, you know, thing to go into. I haven’t really heard of any people saying Oh, I’ve been approached by this person and they, you know, because again, many of those practices if you want to go to a big city, which most of my friends do, many of those practices are being bought up by these companies. And they’re already like, okay, come in, I’m not sure if you can take over because now it’s owned by so-and-so, but come in and I’ll retire pretty soon and, you know. And I think it’s important for the new fellows to understand why people are wanting that to happen and why, what the motivations are for these older physicians and just to understand, be completely transparent and understand when you’re ready to retire, I don’t know what kind of environment you’re going to be in, but this is, you know, how it works, or whatever. I mean, I think it’s important for us to know that.

G: You, you hit something really on the head, which is the folks who are having the most trouble are those coming from small market USA. Why is it you feel that most REIs want to go to, or those of your cohort want to go to, big cities? Is that just a millennial thing and we like big cities and we like the urban life?

V: I think, you know, maybe medical schools could do a better job of recruiting people to go to medical school who are from small towns that want to stay in small towns, but, you know, if you were raised in a larger city, maybe you like that more. I mean, that, that’s certainly what, I mean, I want to, you know, I think, because yeah, because that’s what I grew up with. You know, like, I, I do have my MPH in global health so I like the idea of helping, increasing access to care. And I think that’s really important. But I also think that, you know, being close to family is important, you know. Usually we’ve all been away from our families for decades and finally want to get back. And they typically don’t live in rural areas, but maybe they do and maybe you want to go there. But yeah, I mean, that’s just where most of my family, most of my friends want to go to.

G: Yeah, and then you know, I’m, I’m from Buffalo, New York, so I love small city USA, but I find that often when there is a younger doc coming back to there it’s because they’re from that area.

V: Yeah.

G: And that usually, that’s usually what the attending physician who owns the practice will say, that I got lucky, I found somebody that is from 30 miles away and wants to come back home.

V: Yeah, totally.

G: What are you, what are you most excited about? You know, you got a, a year and a half left in fellowship, or so, a year and some change, and then, you know, and then you’ve got this entire career ahead of you that you’ve prepared 15 years for by the time this is all said and done. What are you excited about?

V: I am just mostly excited to have my own patients and help people have babies. I, and to just finally just start, you know, my career because I’ve been, you know, working so hard to get here. I’m just kind of, I’m just really excited about starting. You know, I’m also really personally just very different from the rest of my cohort and like the business side of medicine because my father, you know, has been a great mentor for me. And so I’m excited to learn as much as I can about that as well. And, and to see where this field is going in the next 10 years. There’s so many new advancements every day in our field, and the research that is coming out is amazing. And I’m really excited to see where we’re, where we’re headed. So…

G: Is there anything about today’s REI fellows that you’d like to clear the air with or just, or give a shout out to your peers, or just anything about this theme that we haven’t talked about that you’d like to conclude with?

V: Yeah. I mean, I think that first, I would like to give a shout out to all of the REI fellows class of 2020, oh my gosh. And also, just want to say, to everyone out there, make sure that you have a transparent practice that you’re joining or creating, and don’t, let’s try to, you know, make an environment for REI practices that it may be necessary to take risks and don’t be afraid to take them. And don’t necessarily fall into the mold of every other fellow out there. Yeah.

G: Dr. Valerie Libby, second year fellow at UH Cleveland Medical Center. It has been a pleasure to get to know you the past couple of years, a pleasure to speak with you today. I really look forward to watching you in your career. Thank you so much for coming on the show.

V: Thank you for having me. It was a pleasure.