113: Building Out an Effective Referring Provider Strategy

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

Listen in to the full episode to learn:

• The 6 pillars of an effective referring provider strategy

  • Make sure your reporting is in line and cohesive

  • Ancillary services

  • Building the right content

  • Having the right events

  • Outreach of referring sources

  • Converting referrals that come to you

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

• If a physician liaison is needed

• How to attribute referral sources properly
  

Additional Resources:

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

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

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Transcript

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

Hi, Stephanie. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Breaking Through the REI Bottleneck with APPs

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

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

Topics covered in this episode include: 

• What your APPs should be doing vs the REI

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

• What to do to have recruiting advantages

• Training APPs 

Connect with Tamara: 

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

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

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Transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And so that could be a possibility. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tamara Tobias: [00:15:47] Yes 

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

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

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

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

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

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

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

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

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

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

For how it, it could be the alternative. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Well, do you really want to be a nurse?

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

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

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

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

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

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

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

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

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

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

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

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

73 - The Academic Fertility Practice: Pros, Cons, and Its Place in the Fertility World Today, an Interview with Dr. Kenan Omurtag

On this episode of Inside Reproductive Health, Griffin talks to Dr. Kenan Omurtag of Washington University in St. Louis, Missouri. Dr. Omurtag shares what he views as the pros of working in an academic clinic, as well as the downsides to working in an academic system. They also discuss the history of the model and what it will look like in the future as the world of fertility continues to grow.

2005 Article from Fertility and Sterility on Academic Medicine

The Ultimate Guide to Fertility Marketing

To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.

***

Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field. 

Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit fertilitybridge.com to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.

GRIFFIN JONES  0:55  
Today on the show, I'm joined by Dr. Kenan Omurtag. Dr. Omurtag is a dual board certified doc in both OB/GYN and REI--takes care of all things related to pregnancy, infertility and reproductive hormone issues. His normal day consists of minor and major surgery cases, diagnostic testing, and procedures such as IUI all the way to IVF to retrievals and embryo transfers. His practice focus includes PCOS, unexplained infertility, male infertility, recurrent pregnancy loss, third party, and--

DR. KENAN OMURTAG  1:31
What’s left?!

JONES  1:32
--advances and treatments. If there's something left, we're going to have to uncover it in the show! Dr. Omurtag, Kenan, welcome to Inside Reproductive Health.

KENAN OMURTAG  1:40  
Griffin, thanks. It's an honor to be here. I've really admired what you've done with this platform.

JONES  1:44  
I appreciate that! What I didn't include in the intro is part of our focus today, talking about the academic practice, because I come up with guests and topics for the show very often when I'm at one of the meetings and I run into someone that I haven't seen in a while and I think, Oh yeah, that's something I need to talk about and that's a person that I need to interview. And on my show because it is focused on the business side of our field, I have left out the academic centers in much of that conversation. I've only had a couple episodes with guests from academic centers on the show and you're one of the very first--I’ve scheduled a few more--but I ran into you and we started talking about this and I wanted to talk about the future of the academic center and how it is today. And maybe to get to that I'm interested in why you decided the academic route as opposed to partnership at a private practice, as opposed to employment with a large network.

OMURTAG  2:53  
Right. Well, I mean, first of all, again, great to be here. I mean, it's been really fun kind of watching your rise in this space. So it's really cool to talk about this topic. I mean, I think if you want to just jump right in, I mean let me jump right into it! If you want to understand where the future of the academic medical center is in reproductive medicine, I think it's important to kind of look at what the history of the academic medical center is in reproductive medicine to understand kind of how we got to where we are. So just for example, you know, one of the first IVF cycles in this country was done with the Joneses at the Jones Institute, an academic center. A lot of the innovation in early ART was in the academic center. Prior to the advent of ART, it's important to point out that reproductive endocrinology and infertility was actually an OB/GYN boarded subspecialty, but it was called reproductive endocrinology and then the infertility was kind of like a lowercase “i” and the reproductive and the endocrine were kind of like the capital letters and kind of drove a lot of the focus of the subspecialty. So in the late 70s, the specialty of reproductive endocrinology was largely focused on steroid hormones, steroid biosynthesis. How do you actually measure an estradiol level, an LH level, an FSH level? And how do you do it effectively in a timely fashion to help augment, among other things, fertility care? But there was also an emphasis on medical endocrine things. But when IVF became a reality in the early 80s, and a practical reality at that, there became somewhat of a schism. Let's also not forget a lot of reproductive endocrinologists were the early laparoscopic surgeons. So what you have with ART is, Oh, we can do this? Oh, there's this divisionary of people who kind of said, Okay, I think this is going to be big. We should invest in this and we should still be REI, but we should maybe focus on the “I” a little bit more, because quite frankly, no one's gonna pay us to take care of patients. I mean, there are medical endocrinologists who take care of patients with diabetes and thyroid issues and all these other things, where our space is probably better suited for this IVF ART thing. So that's where I think the divide starts to happen in the 80s. And then it kind of goes--

JONES  5:17  
As the divide is happening, does that mean that you chose one of the forks in the road or at least--not that they're mutually exclusive, but that they do have different focuses and you wanted more endocrinology in your practice area? How did you make that decision?

OMURTAG  5:42  
Well, to me--so I became interested in Fertility Care in 1996. When I was a freshman in high school and I took a class on genetics, I did a nerdy summer camp, I guess, at Duke. Shout out to the TIP program at Duke University and at the time, they had cloned Dolly, they were talking about gene therapy. And I was like, Oh, this science is fascinating. What's the future medical application? Or what's the medical application because I didn't want to be a science--like a basic scientist, I wanted to be a physician. And IVF was like, oh, this is a clinical application of the frontier of science. Let me explore that. So it was actually the in vitro fertilization, the future of reproduction, that is what attracted me to the field. So in essence, it's kind of the IVF component. The surgery component, the endocrine component didn't really mature until I went into residency and I understood more about the field.

JONES  6:42  
And so now we're at a place, however, where I see that differentiation in practice areas, but I also see, maybe, is there a reconvergence as well? Because to me, it seems that some academic centers are also really powerhouse IVF centers. So is that more--is that still just further stratification of the differences that we have? Or is there a reconvergence because of its practicality and also probably because of its financial impact?

OMURTAG  7:20  
I think is a combination of both. A lot of--so, honestly, the ability to move egg retrievals outside of an operating room into, like, an ambulatory setting is what moved IVF out of the academics. You didn't need to be in this kind of, like, hospital setting, you just needed to be in an ambulatory center. And then this is the late 80s/90s people are kind of managed care is changing. Physician-owned ambulatory centers are popping up as a result. So you have all this, this new delivery care and IVF and the visionaries who were like this is big, we need to do this, are the ones that were were also able to either politically or through their ability to influence their local hospital leadership to help support the new delivery model of this ART fertility care service. So I think what we're seeing now is we're seeing the academic centers are trying to figure out, I think, people are recognizing that there's a niche that in an academic center that can be had. And one of those niches could be, quite frankly, the fact that these academic medical centers have their own employees and their own self-insured policies. And there might be opportunities for academic medical centers to provide benefits that are exclusive to their fertility clinic center, allowing them to kind of provide immediate market to their own clinic. So I think--just kind of meandering back to where the academic medical center might find future benefit--it could be there.

JONES  9:00  
Well, I want to talk about that future benefit, especially related to the prospective physician employee, and pick your brain about some of the pros and cons about working in academic center. And I can think of a few! And I want to see what readily comes to your mind and then I want to further explore them.

OMURTAG  9:23  
Not all academic centers are the same. I think that's the--I mean, honestly, not every private job is the same. They're all very different. But the pros and cons of academia, in medicine, mirror largely the pros and cons of academia of other industries. You know, in medicine, when you're in academia, the primary goal is to do some sort of academic pursuit, whether that's educating or doing some research. And when I say doing research, that's actually you're getting paid to ask--you're relying on grant funding to pay the majority of your salary. That is an opportunity for academia. When you're in private practice or when you're in any industry, your source of income is your labor as it relates to clinical care. There's a lot of that in academia and the nice thing about academia is you can have people who, I just want to focus on clinical care and that's how I want to get paid, but I want to have an opportunity to kind of maybe dabble in these other things. So and I think that's what attracts me to this kind of model is, really good at seeing patients. I can see a lot of patients. I'm efficient with my time, but I can also make time to do stuff with medical student education, resident education, and then every now and then I can dabble in a research project that I don't have to worry about getting grant funding, but I can incorporate in my routine, so it gives me variety.

JONES  10:51  
What I would like to find the answer to--or better said what I'm interested in to just see what plays out in the next 15 years or so is how millennials and Gen Z shape the nature of or the routine of what happens in the academic practice. Because I want to share one of the cons that I see is very often the autonomy of the division--of the division chief is so limited with what goes on relative to the rest of the health system. And it's so bureaucratic that they get very little special attention. If they do get extra attention, it's often top down. They often can't even make decisions on very--on starting an Instagram channel, for example, or they want to do a Facebook Live event. Someone needs to sign off on that, right? So I see it all the time when I'm talking with division chiefs, and I just don't see millennials and Gen Z employees and physicians are taking to that. So are they going to change the bureaucracy of the system? If that is the case is going to take a long time? Or are they just going to say, you know what, I can get a lot of these benefits working for a larger fertility network, and I don't have to deal with as much bureaucracy. And are the academic centers gonna lose out because of that?

OMURTAG  12:26  
I think there's a threat that they will--that they could lose out on talent. So that's something that has to be that is something I'm very sensitive about. The question is, though, what like, what is the mission of the academic department? What is the mission top down? And where does the reproductive endocrinology and infertility division fit in that mission, and that is always subject to change kind of on whim sometimes, it feels like. But also if you're just looking for, like, hey, I want this job. I want to just see some patients, a bunch of patients. I want to be around some collegial people for a couple years, I'm going to build my brand on Instagram by myself where I'll have more flexibility to talk freely without having to get any approval. You can do that in academia. If you want to manage--so I had this experience managing our WashU Instagram, Facebook page, etc, like it is there's a lot of layers, but I was also doing it at a time when they didn't really know how to do it. So they were kind of learning with us. I think the institution will flex with time, but obviously it's not as nimble. A large organization is never going to be as nimble as a small outfit regardless of how devoted they are and what kind of lip service you get. I also think though, with time, I think the--because IVF units, they make a lot of money for their hospitals and I think with time as hospital leadership and academic medical center leadership evolve, I think more and more of those new leaders will have personal and at least know people who struggled with infertility and needed IVF and will have an intimate window and they'll be more sensitive to making the unit a priority or at least advocating for more tomorrow than they did today and yesterday. 

JONES  14:26  
When you mentioned that exercising the autonomy as an individual, that I can start my own Instagram handle, for example, and promote my own personal brand, but is that always possible even if--it sounds like it's been possible for you. I've spoken with others and granted, some of the people that have been in training, but they have had their own social media channels. I don't want to say anything about where they are or who they are, but they did a great job of promoting awareness and educating and it just included their program at a very peripheral level, like maybe they were wearing something that had the insignia of the institution or it was at this setting. And something came down from their boss's boss's boss that said, Stop, delete this immediately. And they're not even sure why, but they've got this mandate to cease and desist from superiors that are further up the chain than they've even met before. And that seems really discouraging for intrapreneurial physicians, for talent, that want to take ownership, that want to educate, that really want to participate, and, in my view, only benefits the program overall. I guess, how often do you see that or what are the implications of that? Because to me, it means Okay, well, I guess I have my answer if I were thinking about continuing with this institution or joining up with someone else in private practice or in a large group, right?

OMURTAG  16:12  
I think, again, all the institutes, every setting is different, but you need to also figure, you kind of also need to be wise about things. If you're going to say, Okay, cool. I'm in an academic setting. I know there's medical public affairs or some sort of office, let me find out who that person is. Let me let them know this is what I'm doing. And let me figure out what the ground rules are for the institution. There are going to be some people who are going to meet some resistance and trust me, I have encountered those people, but after you explain after you figure out what are your what are the rules, okay, you want me to fill this form out and make sure if I'm going to include a patient's picture, I just need to write fill out this form. Okay, cool. You know, two years later, oh, I haven't been filling the form out correctly? Okay. How do you want me to fill it out? Okay, you want me to fill it out this way. Okay, done. So incorporating these things. Yeah, it's annoying when some-- in a private practice, I could just say, hey, is it okay? Presumably, you could just say, Hey, can I use this on social? Yes. Okay, cool. I don't need to have this written documentation, perhaps. Some clinics, some larger private clients may require it to have something in writing. So I think--so I've encountered these things, they can be turn-offs, but they can also be opportunities. So for example, if you're in an institution, and you have skills with social media and patient education and engagement on your platform, you should highlight that and promote that and say, Hey, Dean of Education, hey, Dean of Curriculum, hey, department head, and I would honestly focus on the medical school apparatus. That's what we've done here and say, look, this is a tool, we should do a faculty development workshop, I can help lead it and that's how you leverage your skill and it's not so much, Hey, let me build my platform, you won't let me build my brand, or you won't help me build our brand. It's let me teach everybody in the institution how to build our brand and their brand. Because an academic center, they want to know what can you do for the center-at-large? Not so much what can you just do for your slice of the community? Even though that's what you want to do, you leverage the whole institution to get buy-in about what your skill set is, and then you cash out later to get whatever you need to do your divisional thing.

JONES  18:33  
Does that contradict that potential benefit of just--well, I mean, you mentioned before--if I just want to build my own personal brand, I can do that. But in this case, I have to sell it back to the--or I can't and then I have to sell it back to the group?

OMURTAG  18:51  
I wouldn't say it’s so much I have to--like okay, I want to build the WashU REI division’s Facebook page. Okay, there's some bureaucracy I gotta go through, I figured out what it is. I just have to fill out these forms, I set up the account, they made me an administrator. I’ve just got to use some common sense and recognize that when I post on here, I'm talking about the institution and give me free rein. They're not going to give someone free rein who's just like, I've never done this before I want to do it, they'll probably want to know a little bit more about what your messaging is. And I would have a--if you're a novice to it, then I would say, these are the things I want to talk about, here's the content I want you to post. And here's how I want it. I mean, I'm happy to advise anybody out there on this, because I think this is so important. And I think there's a good path to do it. And there are other paths that can get you shut down, which again, can be discouraging and be a reason why people might not want to deal with it. But I promise you it can actually be very rewarding.

JONES  19:54  
Great, because I don't want to advise anyone on that! So if you're looking for a consultant on managing approvals through a university setting, Kenan Omurtag is your consultant and he's expensive, but it's worth it.

OMURTAG  20:09  
It's free 99 for the first hour!

JONES  20:12  
Can we go through a hypothetical situation? 

OMURTAG  20:15
Sure, let's do it. 

JONES  20:17
And maybe it's not hypothetical, because maybe you've done it. But I think that every fertility center in North America, possibly the world, should do a baby reunion. I think it's one of the best marketing tools that you can use. And it's also so foundational for every marketing strategy that can come from that. When I consult with practices, usually it comes up early on in strategy sessions. The timing of when we do it might depend on its priority for project, but it doesn't take me too long to convince private practice owners of the value. And it's like, great, all right, well, we're going to pick the venue. We're going to get the food, we're going to get the videographer, and here's what you're going to do, here's the strategy. And it's not terribly difficult to implement. It's logistically involved, but approval wise, it's a thumbs up from the practice owner or the executive director. And that's it. We're doing it. If you wanted to do that within an academic center, what would we need to go through in order to have it become a reality?

OMURTAG  21:29  
So we've talked about it here. And actually they did one for, I think the 20 or 25 year reunion here. They did one at the science center, it was a big production. It was, in talking to our division head, he said, you know, it wasn't really that hard to set up. They just told medical public affairs and then the hospital outreach folks and they arranged it for us. That was in 2005, though, how would you arrange it today? It would be very similar. We would reach out to our--so like, I have liaisons that I'm in contact with that I contact and say this is what we want to do. This is what the game plan is. Let's make it happen. And they will ask some questions about it. And then they'll set it up based on what--who they think is going to show up and whatever their experience is in setting things up. So I agree with you. I think these things are--they're very sentimental. They're amazing emotionally on a number of levels. And yeah, I mean, there is a marketing benefit to it as well.

JONES  22:29  
Does the Dean need to approve it or does the Dean's office need to approve something or elsewhere in the university? Or they say yes, you can have a reunion, but if you want to have a videographer there, you need to have this approved or if you want to have it at this venue, we need to put out a purchase order to pay for the venue? What else is involved?

OMURTAG  22:53  
That's a good question. I think it would vary by institution. So for example, I don't know if the university would have some regulatory things. And this is where it can get frustrating. The university might have some regulatory things, or the hospital might have some regulatory things. It's just variable and I think it just depends on the institution. I think in some places, it'll be more seamless than others. I think it always comes down to who's paying for this is always kind of, like whoever's paying for it is ultimately going to be the one that gets to decide what the process is, whether it's the hospital or the academic center, and that can vary. The Dean may not care, the Chairman may not care. It might be a solely divisional process that's led and paid for. It might be the division that drives it and the hospital pays for it. It is so variable. But you're right, if you're in a private practice, there's fewer layers of bureaucracy that are there. So you can just say, yeah, we're doing this, this is what we're doing, we're paying for it and let's make it happen. I mean, that's the thing when you're in the academic center a lot of things are not coming necessarily out of the division pocket, they might be coming out of other people's pockets. And that's what leads to the bureaucracy.

JONES  24:08  
I'm emphasizing these cons or exploring these cons because I'm an entrepreneur. I have a tilt to a certain way, which is I want to have the control and not have the--that isn't important to everyone. I think it is important for entrepreneurial and some intrapreneurial docs to consider. But let's talk about some of the pros as well, because you outline them, but let's talk about the the passions that you have for the Academic Center, that if you're speaking to a certain profile of a physician that's entering the workforce, you would really want them to consider what the academic IVF center has to offer that might be less common in private practice.

OMURTAG  25:00  
I mean, it kind of comes down to really two principles. And that's, for me, at least, it’s variety and opportunity. And when I say opportunity, it's opportunity for leadership. So you have--in an academic medical center, you have a lot of variety. If you wanted to just grind out and see as many patients as you can, do as many cycles as you can, and that way you can get your experience quickly, there's an academic center for you that can help you achieve that. Because trust me, they want you to see patients as badly as anybody else. Because, as they say, no margin, no mission. You have to see a lot of patients in order to generate the revenue to help support the other missions of the institution. So clinical care and the revenue that's generated is very important. And there's that, but you can also have other variety so that you don't get burned out so quickly. Because you can be out here and within two years see 5,000 patients, and then you're like, okay, I'm like totally burned out. I need to explore something else. That might require you to either leave your current situation or try to find something within your current situation that allows you to have variety. And many people often find it, but the academic center provides you more structured opportunities for education and research that may not be as prevalent anywhere, or at least have the infrastructure or the depth that some people want to explore.

JONES  26:38  
So what do you mean by opportunity for leadership? What exists in the university setting that is a track for leadership that one wouldn't necessarily find in private practice or a fertility network?

OMURTAG  26:53  
Well, if you want--so I mean, just kind of starting,if you want to start at the top--if you aspire to be a administrator In a big academic center like a Dean, a Chairman, I mean, take it even all the way up to a Provost or Chancellor, you got to spend a lot of time bouncing around or staying in one academic institution and gathering a lot of experiences over time. That's not to say you couldn't do those things if you were in private practice and came back. But if you want to be a--I wouldn't say necessarily a Residency Program Director--but if you want to be in hospital administration, if you want to be a Chief Medical Officer, if you want to be a Vice President of Clinical Affairs for an OB/GYN department, because you really know how to see patients very efficiently, you know how to implement an electronic medical record, you know how to engage patients with social media. You can have a bigger impact on the institution at large and the community at large if that is your desire. Now, obviously, if you're just, you're like, you know--I'm seven years out these things were always on my personal radar, but my first five year goal was I'm going to be the best reproductive endocrinology and infertility specialist I can, reevaluate with the next five years will be at that point. Here we are, we’re at the next five years. I'm going to push myself to be the most efficient reproductive endocrinologist and fertility specialist and learn how to incorporate an electronic medical record and social media engagement in my daily routine. And I'm going to try to be the best at that. And I'm also going to advocate for those skill sets within the institution to at least promote the possibility that, hey, this is the future of medicine, I might have a skill set that could be valuable to our division, department and institution at large. So can you come over here and listen to what I have to say?

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JONES  30:42
I see that leadership track as something that I--there's definitely a profile of doctors that that’s what they're interested in. I don't think that it's--that type of track exists in parallel with or exists at the same level at a fertility network, let's say. But one benefit that we haven't talked about is the case, I think that had been made for a long time, which is, there's less to worry about that is not related to medicine in the academic center. Meaning you don't have to worry about payroll, you don't have to worry about choosing the HR company, you don't have to necessarily worry about marketing. Whereas if you're a single physician, practice owner or even a partner in a two to four or five group, you do have to worry about those things. And that was very often considered a large benefit. I wonder, are we talking about that less, because there's a third group now? It's no longer a dichotomy between the academy and private practice, but I break private practice almost into two groups entirely, which is the independently-owned, let’s say 1 to however many docs, and then fertility networks, multiple groups, multiple doctors, multiple labs and multiple states, sometimes multiple countries. And now, that might be something that they can offer, the fertility networks can offer, that the academic institutions still offer, but used to have as one of their cardinal selling points. I can go work for this larger group and I don't have to worry about payroll, I don't have to worry about HR. There's a CEO, Chief Human Resources officer, they've got the C suite and the processes in place. Does this new rise of the fertility network disrupt the recruitment appeal of the academic center in any way?

OMURTAG  32:41  
I think it does, but also I don't think it really--I mean, I think it does, just in the sense that you have more job opportunities as a result of the business model. But I agree with you. The “I don't have to deal with payroll, I don't have to deal with my malpractice, I don't have to deal with all these ancillary things,” I think most people are not really interested in doing that any place. And that had been academia’s calling card, you're right. Now that there's this kind of third party or third method, but this has kind of been around for a while now. And a lot of physicians are getting used to--like I came up of an age where, you know, physicians were, it’s kind of like, okay, yeah, cool. I'm an employee. The idea that I would just be under these shingles by myself and setting up the whole thing was something I saw with my own uncle who struggled with that transition. So to me, it was never--I mean, I always viewed my job as being an employee. Now, what I will say though, is the fertility networks may provide new opportunities for leadership over time, not immediately, but there may be new opportunities on the leadership side that had largely been and still are traditionally held by academia. One of the other things that academic centers, you know, talking about a pro, the fertility network will provide you your fringe benefits and all these other things and make it pretty easy for you to just plug and play. But the academic centers, specifically the private academic centers, usually have fringe benefits that are very valuable to a lot of people and the biggest one is a tuition benefit. So for here at WashU, for example, if you've been an employee for seven years, you'll get a tuition benefit, so that your children can go to WashU for free, or they can go somewhere else with 40% towards the cost of that tuition. And that's a big deal. But you could argue, I could go work in private practice, make more money and make that up pretty quickly. So it's, again, you can kind of go back and forth on that pro and con.

JONES  34:53  
I want to go back to convergence because we're talking about fertility networks as one path as academics is another, it seems that they may be coming closer and interweaving in ways that we weren't seeing 10 or 15 years ago. You know, we see certain university systems that their division is owned by a private equity firm or partly owned or they're part of a fertility network. We see private practice groups that have fellowships in concert with large university systems and so-- I'm not too familiar with this area, maybe you can help shed some light on it, but is it possible for any REI division to be sold to a private equity firm or can Fertility Bridge come in with some private equity money and broker a deal with Washington University and say, Okay, now we've got 40% of it and so it is private, but it's also through the university. How does that work and what's the trend that’s happening if there is one?

OMURTAG  36:00  
Yeah, I mean, just purely hypothetical, right? Like, I mean, the example you gave just for the record, purely hypothetical.

JONES  36:09  
Yes. I do not have millions of dollars in Wall Street money yet, unless the right private equity firm is listening!

OMURTAG  36:17  
To your point earlier, yes, we are not trying, we are not scheming something. This is purely hypothetical! No, I mean, seriously, though, again, it comes down to all politics is local, right? I would encourage anyone who's interested in the relationship between Chapel Hill and UNC Fertility Clinic and Integramed, to talk to Mark Fritz and he's told his story about how that relationship came about. I think it really just depends on does the institutional leadership feel like a third party, be it you know, private equity firm or just a practice management firm or whatever--is it better equipped to do the day-to-day operation or satisfy the needs of the division and its clinical services and or its other services for that matter, more efficiently than the current infrastructure? And I mean, I think many times the answer is probably, but it's so different from institution to institution that there might be a financial disincentive in the long term, there might be financial incentives up front that may not be good in the long term. So I think these contracts and these relationships have to be dissected individually. My guess is it always comes back to you know, what's in the best interest of the institution? You know, if the REI division is going to fold, if this doesn't happen, that's a big problem for the department. That's a big problem for the residency program. It's a big problem for the hospital. It's gone down the line, so then it becomes an issue. If it's more we think we can do this better, we think maybe we can make an extra $250k a year based on this and profit wise, maybe the administration is like, yeah, let's do it. Because whatever the negatives are, are outweighed by that benefit. So it's just a cost benefit analysis that each institution has to do based on the relationship and the negotiation between the two parties.

JONES  38:20  
Maybe this is a question for Dr. Fritz or others in similar situations, but does that change the financial relationship or potential for employment agreements or what's in employment agreements between the physician and the system? If, for example, are there partnership opportunities? Can you be an equity owning partner, a shareholder in that institution? So now that you're--does that happen?

OMURTAG  38:50  
I'm sure it does. But I'm curious who gets to be a partner? Maybe not everybody, maybe certain people do. Maybe only one person. Maybe the most senior person who drove the whole project is the one that gets to benefit the most. Maybe a small cadre of people. Maybe everybody does! Maybe everyone is now, you know, university employees, but the hospital runs the whole operation and is responsible for the entire operation and the university is nothing but a symbolic thing and oh, all the physicians keep their University benefits. But the entire project is run and operated by either the hospital, some third party, and they collect all the money, and then they just push it to the University. These relationships can get very complex quickly, because of all the different parties involved, especially in large academic medical centers where you're usually dealing with the university system, the hospital system, and then whatever this third party is. You know, like many places those systems are aligned. Might take partners in Boston, the Harvard Medical System, you know, Harvard Medical School has three partner hospitals and together they are all called partners. But, you know, in a lot of systems, those two entities are wholly separate and they're aligned, largely aligned, but they still have different pieces--they're different components, like our IVF lab is owned and operated by the hospital, but if you walk through a different room, the laboratory that does semen analysis and runs all the bloods is owned and operated by the university.

JONES  40:35  
We have, we have a few guests this year that might be able to share some insight on their experience. And, and I'm going to look for a few more because you've raised some more questions that I'm really interested in and this convergence and divergence of private equity of the of private care and now the university and the health system in a way that I just--this wasn't happening 10 years ago, was it?

OMURTAG  41:06  
It was happening in 2005. I could go back even further. There's a good article--let me tell you this. There's a good article--this, what we're talking about today, as far as kind of the limitations of or kind of like, what is it like practicing our infertility care in an academic center--was talked about by Michael Soules in Fertility and Sterility, Richard Reindollar, Richard Paulson in a 2005 issue dedicated to this question of what is the future of the academic REI practice? At the time, a prominent, I don't really know, Dr. Soules I think he was at University of Washington--and I apologize if I'm getting this incorrectly--but he writes in his article, and I would encourage anyone who's interested in this topic to read this article, he wrote an editorial about talking about the challenge she was facing in the university about promoting his clinical mission and all the bureaucratic layers and everything. And then everyone kind of wrote their own editorials kind of in response. So check out that Fertility and Sterility issue because it shines a light, the same conversation they're having 15 years ago is kind of what is being had today.

JONES  42:21  
Okay, so it has been happening for longer than I had considered. If we're seeing more of it now, it means that there's different types of career paths for people that are going into--whether they're going into a fertility network or private practice or through a university system, there's more. I want to talk about some of the traditional ways that employment agreements are structured or compensation is structured in academic centers. Can we talk about that? 

OMURTAG  42:53
Yeah. 

JONES  42:54
So are most academic systems is there--are most of them RVU based? Or are they all RVU-based--relative value unit for those that might not use that?

OMURTAG  43:08  
Yeah, many of them are. So I get, based on my RVUs I get--we are salaried employees and I get bonus based on clinical production and academic production. So a lot of institutions that will do this thing where they'll have academic RVUs, where you'll get certain points for publishing, teaching, being on a board for something, being on a committee, etc. And then they'll also give you clinical bonuses based on your production that are RVU based. So your base salary can, you know, if the base salary for someone coming out of fellowship is $250 in the academic center, you could get, depending on the structure of the institution, your clinical bonus if you're very pretty productive could get you well into $300 and above, depending on region and all this other stuff.

JONES  44:06  
So if I understand correctly RVUs are typically broken up into work RVUs, which is what we're talking about here. It's mostly what we're talking about when we're talking about RVUs. There's also practice expense RVUs and malpractice expense RVUs. Is academic RVUs and clinical RVUs, is that to say that there's four as opposed to three and each of those two are sort of fill in for work RVUs? Or are clinical RVUs, work RVUs, and academic RVUs, something separate?

OMURTAG  44:44  
The latter. Clinical and work RVUs are the same. And then academic is you know, proprietary.

JONES  44:52  
Got it. And so how are academic RVUs measured? Is that by courseload, or--

OMURTAG  44:59
Point scale.

JONES  45:00
Can that be labs, courses, if you’re the attending for a certain group of physicians--how does that point scale work?

OMURTAG  45:08  
Let me give you some examples. I wrote a, I'm the first author on a paper, I get five points. I'm a co-author, I get two points. I gave a lecture about primary amenorrhea, I get two points. I run a course for the medical students and coordinate 23 hours of whatever content and have to deal with faculty and their schedules, I get 20 points. Those are some examples. I am a board examiner, I get 10 points. And I mean, this is random. But you can see there's like some sort of scaling as to, you know, if you just go give a 30 minute lecture, that's less points than if you spend time managing or you’re the editor-in-chief of a journal, that's 20 points. Oh, you got an RO1 Grant? 50 points. So there's a scale that then everyone's academic RVUs are tallied. And this is again, there's a lot of variety on how this can be done. But people are like, Okay, you got this. So based on the profit for the division or the department or the school, however it's laid out, here's the algorithm that, you know, based on this is how much we have per RVU based on how much total profit, it's so distributed accordingly.

JONES  46:24  
Okay, that makes sense to me. I've seen other systems use what is called--I've seen it called forgiven time or protected time, where let's say a physician has an RVU target and then the institutions say, Okay, but this percentage of time is protected. So that means that they only have to generate--you know, if 10% of the time is protected, they only need to generate 90% of their RVU target or if it were 25 percent and they only have to reach 75%, is that in lieu of having academic RVUs?

OMURTAG  47:06  
No, that would be in addition. So, like, a common scenario in an academic center is like, for example, the medical school will pay 15% of my salary. They'll pay for 15% of my time. Because I educate--I spend time educating the medical students. So in order to get the quality that they want, they have to buy my time. So not only are they supporting my salary--I'm not getting additional money, but my department just has to pay me less because the rest of what they're supposed to pay me for my base is coming from the medical school--coming from another revenue stream. 

JONES  47:54
Okay, yep.

OMURTAG  47:55
But that's how--that's how it works. But I still, on top of that, you know, charge academic RVU time. So I say, hey, look, I'm doing this, I'm still doing this, I'm still doing that. And I'm still seeing all these patients too. So you can generate, depending on the structure, you can fight for kind of your time like, hey, look, I spent all this I spent six hours a week managing a social media account for the division. Maybe it makes sense for me to ask the department to pay for 10% of that time, because I'm going to also manage the entire department’s social media account. You want to do it right, you’ve got to pay me for that time. Oh, we don't think it's important to be paying this person. Okay, fine. Well, then, you know, I'm going to--you don't have a category for it in the academic RVU, make one or I'm just going to put it as 20 points, which is what I did.

JONES  48:43  
Yeah. So does it typically happen when there isn't a category in the academic RVU? Is that typically when time is bought back?

OMURTAG  48:52  
Well, the nice thing is most of the--again, I'm only speaking from my experience, you can just fill in what you think you deserve and they can decide if they think it's worth it. If this is worth giving, like, obviously I'm not going to say, Hey, you know, I drew this picture of how IVF works, 4000 points you know,? Like I'll probably say five points. I made a video, I put it up on the web, it took me some time, so it’s five points. I tried to calculate how much a point is worth, but I wasn't able to get to that, but it was actually worth a couple hundred bucks. So, I think the scale actually works nicely.

JONES  49:35  
Who does calculate the points and then who calculates, this is this service is this many RVUs and then who calculates the compensation for that?

OMURTAG  49:45  
The department management does that and it's subject to change depending on the profit of the entire department. Is typically how--

JONES  49:55  
Do they vary widely from university to university? If we’re at Stanford, would we expect to see something very different at the University of Iowa or in Florida? Or do they tend to do--is a retrieval generally this many RVUs and a transfer is this many? Are they similar?

OMURTAG  50:17  
So for those CPT--yeah, they should actually be the same as far as what the RVU multiplier is. As far as I know, I'm not gonna pretend like I'm an expert in this. RVU multiplier for the procedure should be the same largely, although I don't know if the multiplier changes by region, or if the dollar amount changes by region. There's probably some calculation of that--

JONES  50:43  
I believe it's the latter but I would love for anyone that's listening to correct me if I’m wrong and they'd like to speak on that. I think that's very useful. How many academic RVUs and how many clinical RVUs can a new doctor let's say it's a doctor that's maybe in their first or second year of employment, expect to produce each year each day?

OMURTAG  51:07  
How many academic ones?

JONES  51:10  
Yeah, so how many academics and how many clinical?

OMURTAG  51:14  
Okay, so well the work RVU is obviously just a function--again, like, hey, we're going to start you with four patients and you're like, no, I can see five, that will help drive your downstream work RVUs because if you see that extra patient a day, or a week or two to three a week, those are going to generate more opportunities for a procedure, which is going to generate an RVU and again, depending on--or an ultrasound, which is going to generate a clinical, you know, work RVU--again, all of these are wholly dependent on the local fee structure and how things work. But if you want to boost your work RVUs, you just see more patients, and you figure out a way to work it in.

JONES  52:03  
So are the targets set? You know, let's say if like, I don't know, let's say the average doctor’s expected to produce 9000 RVUs a year and then maybe you take out 100 weekend days and maybe you take out 65 vacation, sick days, etc. Maybe you've got into--you're dividing 9000 by 200. I guess. I don't know what that number that would substitute for 9000 actually is or if you have 45 work RVUs as your target per day, how that is balanced with academic RVUs?

OMURTAG  52:46  
Well, I think it's--you’ve got to figure out, Okay, what is probably the most value. Like what am I going to get? if your work RVUs are dictating your salary and/or your bonus more so than your academic ones, you're going to focus on how can I maximize my work RVUs?

JONES  53:10  
So are you saying that that target is constructed by the individual? They can say I want to spend more, I want to have a higher clinical RVU target than an academic target? Or is it set by the department? They say this is your target for academic and--

OMURTAG  53:27  
You know, I'll tell you, it is variable. All I can really speak to my experience which has been, you know, usually the clinic will tell you, these are how many days of clinic a week you're supposed to be doing. So they may not have a work RVU target. They might say you need to be in the clinic, four days out of five, seeing patients eight to four, and then you can have this fifth day off as an administrative day to do whatever it is you want to do. Like, some of these contracts from the academic center might say, your contract is for four half days a week and then you can kind of do whatever. That's all the contract says. There might not be an RVU target in that contract, which is crazy. It’s not in the contract, but someone will tell you, hey, you're not seeing enough patients and you can be like, but I thought you said I just needed to do four half days a week?

JONES  54:36  
Well, this is one of things--I often criticize employment agreements in private practices that, particularly with eligibility for partnership, eligibility for buy-in, it's not enumerated very often in employment agreements. And so I thought, Well, certainly systems that use RVUs would have that enumerated, but you’re saying that’s not always the case where targets are enumerated.

OMURTAG  55:02  
No. I mean, no one has said--I mean, I get monthly updates as to where my targets are and how I'm doing and I usually compare it. And I'll tell you the first year I was like, What the hell is this? I don't know what this is? Can someone explain it? I mean, I conceptually know what it is, but I don't know what it is, honestly, let's be real. So then I kind of said, Okay, I did this amount. So I guess, okay, this amount of RVUs led to, and academic RVUs led to this bonus plus my base. Okay, that was my target. Alright, cool. So maybe I should stick with that or maybe cool, I wasn't that busy, there was some other stuff. Let me push it next year and let me change the schedule. So I have some autonomy in my current setting to kind of set A) let's do a little bit more here or let's kind of back down a little bit on this side with obviously a sign off from leadership.

JONES  56:04  
Well, you taught me a lot more than I knew about that subject. And hopefully for the listening audience as well, especially those that are mapping out their career path within the next few years. I'd like to conclude with just how you see the future of the Academic Center and the participation of entrepreneurial physicians because I very much include you in that group. You and I met at my very first meeting in the field. So a lot of people don't know this about me, but I had moved back to the United States in 2015. And I didn't know anyone at that time. I went to MRS, which was the Midwest Reproductive Symposium, a meeting that I was unfamiliar with at the time. You were speaking. We started talking because your topic was about social media. And that's how I broke into the field was originally just through Facebook community management, which grew into social media, which grew into digital marketing. And a lot of people are familiar with my book, The Ultimate Guide to Fertility Marketing, because it's what they download. But there was actually a book before that. I don't even know if I still have a copy of it digitally anywhere! It was called Digital Marketing for Fertility Centers.

OMURTAG  57: 23
I remember that!

JONES  57:25
In which you were a contributor, and your name is on that as well. And so I think you may have been the very first person that I ever collaborated with someone on content within the field. Then we didn't talk for three and a half years and now you're back on the show, but I do consider you one of these people that's very intrapreneurial. And so I'd like your thoughts on including of how that intrapreneurial profile, someone who wants to add to the system, not just say I'm already following an established process, but rather contribute to it. What's the future for them and consequently, for the Academic Fertility Center REI Division?

OMURTAG  58:14  
Wow. I mean, I appreciate the shine, man. I mean, I'll just say real quick. I remember after the talk I gave in Chicago, you were like, Hey, man, you should maybe think about this Instagram thing. And I was like, is that what people take pictures of their food and stuff? And you're like, Yeah, and I was like, What about Twitter? And you were like, Nah, man, that moves too fast. You should check out Instagram. And I came back to Instagram like two years later and I'm like, yeah, Griff was right. This is where the action is. This is the best platform for this. So shout out to you man and what you've been doing with Fertility Bridge. I do also remember reading some other blog of yours about and it probably was on Fertility Bridge, just about the future of the field. I mean, I think your insights are pretty accurate and kind of the way I see it is pretty, like--what I read from you is like, I'm like, yeah, that's pretty spot on. So anything I can do to inform the academic side, and really the field in general to add to your knowledge and your community, happy to do! So as it relates to the future, I don't think I'm the first person to say this, I know I'm definitely not, but I think the future is going to be for the field in general, is going to be about consolidating and using IVF as a treatment tool and a prevention tool for disease. I think we'll see more of that. And I think that will be regional at first, but I think over time, that will become more widespread, given the ability to test embryos and the potential use of CRISPR. While terrifying for a lot of folks, maybe inevitable for others. I think that's something we'll be dealing with in our lifetime, for better for worse. But from the academic--I think the other thing to point out is what is the role of the academic medical center in medicine specifically in reproductive care? Because a lot of the innovation, and a lot of the tinkering in science usually comes out of the academic centers and then gets pushed into practice. That's not--like in our field, that doesn't really happen that much anymore. I think ICSI was probably the last thing that came out of a purely academic pursuit. I mean, there might be other things I'm missing, but I think the biggest role the Academic Center has to play in pushing forward the progress of Fertility Care is in its ability to provide access to Fertility Care. Academic institutions are large. They have 15-40,000 employees. State institutions are big. Times are changing. And employees want a fertility treatment benefit, who better to give it than their employers. And I think fertility clinics and reproductive endocrinology divisions have an opportunity to lobby university and hospital administrators to make carve outs for institutional employees that are exclusive to the institution’s fertility practice. I think that will be the future of the academic medical center and how I can leave its best imprint on the reproductive endocrinology and infertility division and its surrounding community. 

JONES  1:01:27  
All capital letters. Dr. Kenan Omurtag, thank you for your kind words. Thank you for your contribution to the content over the years. And thank you for the insight that you gave us today on the show.

OMURTAG  1:01:39  
Yeah, thanks for having me, man.

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You’ve been listening to the Inside Reproductive Health Podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society, visit fertiltybridge.com to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.