As we head into a new (and hopefully better) year, we wanted to take a look back on all the wonderful, inspiring guests we had on Inside Reproductive Health throughout the year. We talked about affordable care, mentoring new staff in the clinic and the lab. We learned about independent clinics and how they thrive despite heavy network competition, networks and how they continue to provide personalized care even after becoming publicly-owned. We talked about reducing physician burnout and increasing patient communication. And so much more.
On this episode of Inside Reproductive Health, we highlighted your favorite episodes and compiled the best clips into one episode for you to enjoy as 2020 wraps up.
Find the full episodes here:
77- Is Work-Life Fit Attainable for All Fertility Doctors? An Interview with Dr. Stephanie Gustin
53 - Has Mentorship in the IVF Lab Suffered Due to Strained Staff? Interview with Bill Venier
59 - Retaining Patient and Physician Focus While Growing a Clinic, An Interview with Michael Alper
52 - The Independent REI Practice: A Business Model That’s Fading or Relevant? Dr. John Nichols
54 - Improving Patient Experience by Building an Empowered Team, An Interview with Dr. Peter Klatsky
87 - Restarting Growth After Plateauing, an interview with Dr. Matt Retzloff
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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.
JONES 0:38
Well, 2020 was a pretty boring year, pretty uneventful, especially in the infertility field, so nothing to see here. Well actually, it was pretty darn eventful. So I wanted to wrap up 2020 with a style that’s a little bit different on Inside Reproductive Health this time, wrapping up with some of the highlights from our popular episodes throughout the year. There are a lot of episodes that I repurpose all the time, that I send to people, that I share in other places. These ones that made the Best Of--it just has to do with the year itself. So there were a lot of really great content to choose from. I chose these episodes because they tie into the ups and downs of 2020. From my interview with Dr. Stephanie Gustin talking about work/life fit to hearing from doctors Mark Amols, Paul Magarelli, Rob Kiltz, that all discuss the affordable care model, here's our top interviews from the past year.
If you're interested in listening to any of these episodes in their entirety, you can find links to each of these episodes in the show notes.
1:40 Dr. Stephanie Gustin of Heartland Center of Reproductive Medicine…
JONES 1:44
...I can see that the work/life fit frame making a bit more sense because I think you are just somebody that needs to have so much in different areas. And for you, that being a partner in a practice is what allows you to fit it all in, is that a fair assessment?
GUSTIN
Yeah. Absolutely.
JONES
Whereas for others, it might be like, Are you kidding? Learning about business is not exciting at all! I sure as hell don't want to teach a workout class, maybe I want to, you know, run a couple miles a few times a week. And I'm good on that. Whereas I feel like the profile you're describing is one where you want to expand your business knowledge, you want to have the involvement in academics that you talked about, you still want to be a clinician. Fitness is super important. And that it sounds like the track that you've taken of becoming a partner in an independent practice is what allows you to fit all of that in. Do you think that someone can be successful doing that today if they don't have that personality profile?
GUSTIN 2:59
Yeah. I mean, you have to be willing to have balls in the air and figure out a way to juggle them. Right? Because it is putting more hats on your head at once. And that sort of level of trying to quote unquote, work/life fit you have got to be comfortable with that. But I think there are ways you know, certainly I think some people were really smart when they went into medicine, they got like an MD on the side or you know, things like that, that would make it easier. But I think most physicians also went into medicine, because it's a continuous learning curve. We are required to continue to learn all the time. And I think that when you go to seminars about physician burnout one of the things that come up a lot is like, what else can you do to make you happy, right? Like, can you have a side gig? Can you do something that's outside of medicine? Can you, you know, if they’re, like, living near wine country, plenty of physicians that own wineries for example, or you know, this, that or the other. And for me, at least at this point at this point, because the business side of things is so new, it's very similar to that. And I think if people acknowledge where they need help, right, like it's not, I think it takes courage to ask for help. So it's not something--I am very forward that I don't know a lot about what I'm doing, and I'm willing to learn and then I'm willing to rely upon the people that we have set in place to help us navigate it. I think acknowledging that there is a learning curve that is quite possible for many people to succeed, but you’ve got to trust that you are worth it and you’ve got to believe in yourself.
4:33 Dr. Lowell Ku of Dallas IVF…
JONES 4:36
And so what was that transition like going from a practice that had been in business for 10 years with one principal at the helm to now having--I assume you started off as an employee, but then a partner--what was that transition, like going from one to two?
KU 4:54
You know, as a fellow we never ever get any sort of training or teaching on partnership. They never tell us about the business of medicine. And so partnering was always this sort of mystery that was shrouded in secrecy that no one ever, sort of, talked about. So I'm really glad that we had this opportunity today to really put a voice behind and to really to kind of take back the curtain and show people how it works, at least in our practice. So the way it works is when you start in our practice as an associate, you're an employee. And typically in Dallas, it takes about three to five years before your practice is pretty mature and that you're humming along seeing patients. So after the first year, we know that the business is going to be able to basically support that associate and the second year we think that associate might be able to support themselves and then the third year, we think the associate is going to take off and then they should be able to partner after the third year at our practice. Some of our associates haven't been able to partner after three years, but that's okay. They partner at the third year and a half or maybe at the fourth year. So we're very open with our associates. We show them from day one, how they're performing within their business--in our business model, in our business plan. We show them the numbers, how are they performing and then we kind of let them know that they can hopefully understand that, Okay, I need to maybe market myself more, try to build my practice even more, so they can understand how it works. So we'll support them for the first three years and then once they partner, then they can enjoy some of the headaches that I have as a partner!
JONES 6:21
Which was the more difficult transition going from one to two or two to three?
KU 6:26
I think two to three for us was the tougher transition because from one to two was sort of easy because he was--the senior partner was so full of patients and busy. He was actually turning away patients, so he was losing business. So he thought, Well, maybe we can have a second person to sort of capture that, that business with the practice. And then once I started coming on board, it took a little longer for me to get started just because more and more fellows were graduating and coming to Dallas, and we were competing with each other and so it slowed us--slowed me down a little bit. So to go from two to three was harder for us.
JONES 7:01
And then, and not just in terms of volume of building one's own practice, but just in terms of the structure of the organization, do you feel that you know there's a real shift from--is it two to three that is the biggest is it four to five? And now you're at seven so you've got a bell curve to analyze--where do you think structurally operationally, you really start to see, okay, we need to have different systems in place now?
KU 7:22
Absolutely. The infrastructure that we had built now really started to come into play in that we needed it around the after the fourth one was hired. We really needed to have an office manager that understood how to run a bigger practice. The office manager that we had at the time was with the practice for a long time, but she wasn't, sort of, experienced to run a larger practice that we had to find someone who had more experience. So we had to build this infrastructure. So we had to find a practice administrator, as well as an office manager, as well as financial counselors and coordinators, and actually marketers--we started to hire marketers. And so the infrastructure really started need to be formally founded after the fourth one was hired.
8:03 Bill Venier of San Diego Fertility Center…
JONES 8:06
One pain point that I often hear practice owners and executives talk about is retention of IVF lab staff. It's not something that I can really counsel on, so I wanted to bring someone who can. And first, maybe, can you give us some context of--is this a problem that you see across labs? I know you talked to a lot of other lab directors and have relationships with a lot of different groups. Is this an isolated phenomena that some people are seeing more often than not? Or is this something in the field where retention of IVF lab staff is really an issue?
VENIER 8:45
It is an issue, Griffin. It's tough to recruit new people and get them interested in our field. There's not much out there from an educational standpoint, there is a few Master’s programs and things like that, but a lot of those are people that are already in the field and have already attached to a lab, but, you know, want to get the book smarts behind it and some education behind getting an FTS technical supervisor-type certification. And then you have to worry about training someone and then once they're fully trained, are they dedicated to staying with you, or essentially, once you're trained, it's really the demand outweighs the supply. So these people can go wherever they want, to be honest with you. So you have to do some special things to keep your staff intact.
JONES 9:31
It seems to me like the problem of one should be the solution to the other. That is to say, if the problem with retention is because they're so in demand and they can make good money and have different career options, that should be enticing for recruitment. So why is the same problem that we're having with retention--meaning people can go anywhere--not drawing people into the field for recruitment?
VENIER 10:04
That's a great question. Because early on, you know, when I first got in it, most of us were Animal Science majors, so we already had a career in something else. We had the manipulation skills with eggs and embryos, and that type of thing. So we were semi-trained already, before moving to the human field and human IVF labs. Nowadays, they're coming to us with really, absolutely no experience and the time and dedication that's needed to train someone is really putting a strain on the lab. The workload has increased, so our time has decreased to train people. I'm not sure if that's answering your question directly, but you know, once you have someone trained, there could be someone down the street or an hour away that says, “Hey, we'll give you double what you're making,” or something, you know, ridiculous like that. I mean, the lack of supply is definitely driving up salaries. And we have to keep up with it. And it used to be, hey, let's look at this every three to five years. This has to be looked at annually and you have to get together with local lab directors in your area, even if the physicians don't get along, the embryologists tend to get along. The lab directors need to get together, meet a couple times a year or something, hey, this is where we're at. This is in the range of what we're paying the tiers of embryology. You know, where do we fit into that, and those types of things and that's going to change in each region.
11:39 Rita Gruber of the Gruber Group…
GRUBER 11:41
…the good people start leaving. Have you found that to happen?
JONES 11:45
I’ve lived that! ! I've been that person in the corporate world. And it's part of the reason why I wanted to start my own company because I noticed--I worked in radio advertising and sales for my first real job and did that for half a decade. And I noticed that the people that were excellent, that brought the most value to the company, were treated the same as the people who were cancer cells within the company. In fact, sometimes they were treated worse because they didn't complain. And sometimes the people that were the cancer cells were the squeaky wheel and got more attention. And it really made for an organization that wasn't high growth, that wasn't forward-thinking, that wasn't adapting to change. And I thought it would just be so much better if the good people were rewarded, the middle people were mentored to perform more like the great people and then the lousy people, if they really are sabotaging, are let go immediately.
GRUBER 12:51
Well, that’s correct. Absolutely correct. So, you know, again, that's you could have another podcast--seriously--just on performance management and talent development within a practice because, yes, time and time again, if you have physician leadership that isn't paying attention, and you have department managers or leadership that are not listening appropriately, even to the silences, you start losing the good employees who say, you know, what, am I stupid? You know, I do my work and her work to get the same amount of money, no recognition, and she's still here getting an average performance evaluation. I don't think this is the culture for me to succeed and grow. So we're back to the mindsets, starting with the founding physicians down throughout the practice. That service and developing others is a key ingredient to patient success and good patient outcomes and the growth and the financial success of the practice. But yes, a practice cannot, cannot sustain good patient outcomes, good patient volume, good reputation in the community and growth and financial success unless they decide to achieve good leadership skills. Now, nobody's going to be the perfect leader. But that good physician leader will learn how to depend on others to share the journey. And usually that could be the CEO--learn how to depend on these people and their expertise. Learn how to depend on your clinical manager and her expertise, etc. And that's good leadership. Also admit what you don't know and don't have time to learn, so I’ll depend on your expertise. And then as you see the successes, you will trust these people more and more. And respect and trust and influence are all critical in a good leadership culture.
15:22 Dr. Michael Alper of Boston IVF…
JONES 15:25
So you've got the administrative team in place, you've got a Board of Directors, you’ve got 14 partners, you've done acquisition, you've merged with another big group up until this point. Now, how do you collectively make the decisions of you know, let's pursue private equity or let's entertain this offer that PE firm has presented to us and I'm sure you get plenty of those calls. How do you make that decision together?
ALPER 15:52
So as you may or may not know, we've partnered with an entity called Eugin, which is a company in Barcelona in Spain. Actually Eugin is one of the largest--next to or in parallel with IVI--the largest company of IVF centers in the world. Eugin clinics in Spain, Italy, Denmark, Sweden, Brazil, South America, and now the US with us. And they're a strategic partner because they're in the field. We've been approached by numerous private equity firms over the last three years, mainly because we're national and obviously large-size, and I must tell you, we didn't have the right fit because as you know, private equity is there to invest for the short term and increase the profitability and then sell in three to five years. And that's not my horizon. And I would venture to believe it's not the horizon of most physicians, although some physicians are interested in exiting, you know, in three to five years and private equity could be the way to do it if that's their personal goal. But we're more longer term players, we have young physicians in our group, we see our field is growing. And we really want to have a partner that was more strategic. So it's an individual choice for anybody who's being approached. But you know, what I tell all my colleagues and ask me these questions, I say, the most important thing about these transactions is what the day is like after the transaction closes? Because, you know, these are the--
JONES 17:25
Which I think the jury's still out on a lot of this right now, because a lot of these deals are only a couple years old at this point. So what the day is like, I think we're finding out right now, in many cases.
ALPER 17:38
I'll tell you-- and I'm just being totally frank with you, Griffin--is that I'm quite concerned about it. quite concerned about it because when money takes over medicine, it's not in the best interest of patients a lot of the time. And medicine is not, and specifically reproductive endocrinology, is not like dentistry. There are a lot of emotions, it's a complex thing and I worry when a company owns an IVF program, and their focus is on the money, it could be a real problem. And then the interest of the major investor and the remaining shareholders start to diverge.
18:19 Dr. John Nichols from Piedmont Reproductive Endocrinology Group…
JONES 18:23
I know you're getting people knocking on your door. Why haven't you gone down that route yet?
NICHOLS 18:28
Well, listen, when we first became sort of a presence, a big enough practice that we were getting some motion, people were hearing about us--and you know, I was approached by several of these already. Integramed, that really was kind of the first, as you’re aware. They were sort of the first to come into the fertility field and set up these networks. And there were several practices in my area not that far away that are Integramed practices. And I know the people there and they were like, “Oh, John, you’ve got to join this network! Come on. We want you to be involved!” And I was like, “Show me the numbers. Show me where this makes sense to me. Because I'm not quite sure I understand why I need somebody to manage me. We're managing our stuff very well. I have a great office staff, great office manager, we're doing all the things we need to do. And we don't have to outsource, you just have to hire good people and competent people and take care of those people.” That's probably the most important thing. And when they came and showed me the numbers I just said, “Listen, I'm basically going to be paying you a lot more than what I already pay my people to do now, and I don't see the benefit of it.” And so from the start, all is sort of left a bad taste in my mouth about how this would work. And then as I see more and more of these other VC groups coming in and buying out and, of course, I hear from these docs that have been in the systems and I'm hearing what's happening. Yeah, it may look good up front to get a cash prize, so to speak, but at the end of the day, coming back in and being an employee, and then having somebody else that's outside running it. This is a business, don't get me wrong, but it's not the same kind of business if you're running a car lot or you're running, you know, some other type of service business. Our business is predicated on once again, taking care of patients. And if you can't do that, well they say, well, you have great nurses or you have great embryologists, and you want to compensate them for that or bonus them for that, and when you have corporate saying, “Well, no, we don't do that. Or no, this is a pay cap. In fact, we have to drop their pay down because that's more than what we expect to pay.” And so those kinds of things really limit what you can do to take care of your employees and make them happy and at the end of the day, that's all about how you take care of the practice and the patient. Because when they're happy, they do a good job, you're compensated, they know that you're into them, they know that you’re bought in, and they become vested, and that's how you run a practice. When people are vested, and people have the, you know, go the extra mile, hour, extra phone call, whatever it is, to really take care of the patient. And that's not going to happen in those things. It just, it just can't. It's not part of that system in practice. So that's the biggest reason why we stayed away from it. It just doesn't work for our model.
21:08 Dr. Francisco Arredono, author of MedikalPreneur…
JONES 21:12
So I think their argument would be Okay, Paco, we're bringing the general knowledge and then we're hiring people with the specific knowledge to be our Chief Medical Officer. And I'm not talking about any one group because the narrative is similar in that they say, we're not influencing operations. Thet concern from clinicians is they're going to influence clinical operations and the response is We are not influencing clinical operations. We're influencing business operations. But even as someone who's myself as a consultant, as we start to advance, just beyond marketing consultant, the more we consult there is an overlap, where we're starting to consult people, it's like, Well, we're consulting people on business, but it does affect what they do clinically. And I can't tell a physician what to do. I can’t. But a private equity person could if they own a piece of their company, and so talk a little bit about that.
ARREDONDO 22:14
Yeah, there's actually a couple of articles that will respond to that. One of them is a Harvard Business Review article from a couple of years ago that it says why the best hospitals in the world are managed by doctors. And if you think about it, Mayo Clinic, Cleveland Clinic, John Hopkins, that consistently are on the three tiers of best organizations in the world, from inception, are managed by doctors. And why? Because you're required credibility. Remember what I told you about--
JONES 22:57
You’re thinking of credibility?
ARREDONDO 22:59
Yeah, so correct. I will tell you about trust. You know, physicians only trust physicians in a lot of ways. So, if a physician comes--a physician that has walked the walk--it has more credibility, not only for the physicians, but also for outside stakeholders, patients, the suppliers, you actually have a lot of credibility to external stakeholders, future employees, the pharmaceutical industry donors, a lot of other people. you will have credibility, because what happens is that if the other article is something that he was talking about private equity in healthcare during the COVID era, it was in Bloomberg Businessweek, I think it was in May of this year. And basically what it says is that, yes, in theory, it sounds nice that obviously private equity should not interfere with the data decisions, but when their only focus is to make money and the physician’s duty is to provide care, then it happens that physicians are serving two masters: the patient and the money holders. So it's actually very hard to do that balance. And as you well mentioned, there are certain examples where they are putting the incentives of your service, of your salaries. Remember those physicians that we've said that $300,000 of debt, and they're putting them a carrot that if you do more of these procedures, you're going to get more. So, the way you actually incentivize, it may be against the patient’s first interest. I have to emphasize that not everybody, every company does this and not every private equity thinks that way. It must be clarified, but you can see that there is an inherent conflict of interest by you as a physician having the patient as your first master, and then we have another master. So that's why I say unless the physicians play a role in the boards, in the management, embryologists in our field, embryologists, nurses, play a role in the management team, because in the other article that I mentioned about in Harvard, of the hospitals, there is good evidence that when you separate the clinical and the administrative in like two silos, actually the quality of the markers in the hospital goes down. Those two silos need to be in constant talk, and even more in constant interaction and sometimes they ought to be the same. So there is good evidence in companies that when you silo administration and clinical, the communication doesn't occur. That's one thing. The third thing on the private equity, which is, you know, intentions are good. And that's what I would say that the intentions are very good, which is to become more efficient. The topic for the future is going to be that as we went to an era of globalization, and we're going back to the middle, where everybody is the same, and we're going to centralize accounting and centralized medical records, because that makes sense. It's more efficient. It makes perfect sense. The challenge of the company to the future is that more and more companies and more and more consumers want something local, want something much more local. So private equity management firms and physicians need to ask the question, yes, we're going to become more efficient and more centralized, in what? Perhaps electronic medical records, perhaps in accounting, but what it is working at the local level, keep it up to date. And, you know, I was talking to another industry, I was talking about one of the difference between private equity firms in Sweden and in the United States. I was talking to a friend that has a big company, not in medicine, but it was acquired by a Swedish company, that it is in the stock market in Sweden, and they have companies throughout the world. And they said, the only thing we want you to centralize is the accounting. I want you to do this accounting with this system, you're going to have these people, but the reason I'm buying you is because you’ve been doing so well, otherwise, I wouldn't buy you. And so we want you to continue doing exactly the same thing you're doing. The only thing we're going to do is we're going to make it efficient at this level. And we're going to help you with connections and this and that. But what is happening sometimes, especially in the--because there's two groups in our field of medicine, the ones that are working by acquisitions, and the one that are growing organically--the ones that are working by acquisitions have the challenge that they have to merge cultures. And that is very difficult to do.
28:39 Dr. Bradford Kolb of HRC Fertility...
JONES 28:42
I don’t want to jump ahead, but you've definitely tempted me because I think the IPO is really unique. It's not terribly common in our field. We're more used to talking about private equity, a few private equity firms purchasing groups. We have had companies be public in the past, IntegraMed was public for a while and Sagard took them off of the market. But what was that journey like? How do you go from being a growing group to deciding this is the right move? How did those discussions even start back when they were a pipe dream?
KOLB 29:21
Well, how did it go or how, you know, I'll tell you, is difficult because we started this process on an inquiry of a patient of mine from China. And he kept insisting that he wanted to buy HRC Fertility. So eventually, I threw out just a number off the top of my head of what it would take and he said, “Okay.” We didn't ended up going with that individual, but then there was discussion--
JONES 29:50
Was that a “forget you” number? We’ll use the polite term for the gentle ears of our audience. But was that a forget you--like, for example, I have a forget you number that is a title sponsorship for the podcast because I actually don't want someone to buy the title sponsorship of Inside Reproductive Health. And that number will only keep going up if I feel like people are getting closer to it. But I guess, worst case scenario if someone really wanted it, I would find a way to live with it. Was that number that you first got, was that sort of a, you know, a get lost number?
KOLB 30:29
Actually, it wasn't because we've always entertained like, what is our exit strategy eventually? And we have partners that have massive practices. I mean, both myself and Dr. Wilcox at HRC, we each perform over 900 egg retrieval cycles a year each individually. So, you mean how can I transition that practice to a new physician and get some valuation for that on my retirement? It's impossible. So we've always looked at, okay, is there a possibility to transition the practice over to another entity or individuals? The other thing that we really wanted to look at is how do we expand and grow our practice? And we need financial resources to do that, but we need a lot of business expertise and guidance to do that as well. We’re very good at being physicians. We became very good at dominating our local marketplace in Southern California. So we had a much bigger vision for HRC. So when I threw out that number, it was based on strictly business principle. This is based on our EBITDA, this is the valuation of our practice or the amount of crop that we were bringing in the multiples that we were expecting based on sound business principles is what guided that. And it became an interesting discussion. But once we opened that box, there was a flood of activity. So we actually spent almost a year with that individual’s group. He assembled a group, but became an impossible ordeal for us. We were going to lose our practice, we're going to lose our control of the practice and just simply become an employee of HRC. And that was completely unacceptable to us as well. But we went through about a dozen groups, private equity groups, and different opportunities. We had groups out of Canada, the US, and China, and Hong Kong, that were interested in either acquiring a portion of HRC revenue streams or developing something much larger. And the group that we eventually settled on with Jinxin Fertility. So they came along after a year and a half of these discussions. We became very, I would say savvy is the best word I can think of off the top of my head about what we wanted, what it's going to take to accomplish this and they were on board for it. They shared the same vision about increasing our dominance in California and the West Coast, continuing with good medical care, allowing the physician to control the practice as far as the practice of medicine. And also they brought a vision about creating a global practice. So not only are we HRC Fertility, we have two partners in China, one in Chengdu and one in Shenzhen and they collectively do approximately 35,000 egg retrieval cycles a year. So it's created this unique opportunity to expand the clinical business but also start to look at how do we develop research and how do we develop a global practice that is not just a sum of its parts, but is unique and can develop unique avenues for patient care and improve patient care and opportunity, opportunities for physicians, nurses and staff alike.
34:02 Dr. Peter Klatsky of Spring Fertility…
JONES 34:05
I think of innovation like that, which is groundbreaking in some ways and other things that other people are doing and it harkens back to something that TJ Farnsworth had said on the show a few weeks ago. And I actually really agree with that I've thought about both before and even more sense. I want to see if you agree first off, if you don't, why, and if you do, what do you think can be done about it, but his sentiment with coming from the oncology field was that there is less peer-to-peer sharing of best operations practices, of best practices both from a business and clinical setting. And I really do see that, Peter. I really see it from independent owners, especially, I think where everybody feels like they've got the secret sauce. And maybe you're a guy that really does have the secret sauce and you think, “Well, I do and I don't want to share with folks that are doing the same.” First, do you see it that way? Do you see that our field isn't nearly as collaborative as it could be? Why or why not?
KLATSKY 35:09
I don't. I think--I don't see it that way and I’m sad that TJ feels that way. I actually think that there are--I started this off by saying we followed great minds and great practices that shared their advances in our field. And I don't think oncology even moves as quickly as the field of fertility does and oncology moves incredibly quickly! But why do we have egg freezing? Because of a commitment to have somebody in Japan carried forth with clinical trials performed in Spain and those publications came out in 2010 and by 2012, egg freezing was no longer considered experimental in Europe or the US and people weren’t traveling to other places to learn how to do that. I think that Richard Scott and Bill Schoolcraft, shared advances in pre-implantation genetic testing with the field. So I don't know that there's been a lack of peer-to-peer sharing, even when people have secrets--before we opened up the lab, we had Barry Behr who's lab director for Stanford, which is maybe 40 miles away, walk through our lab and tour it with us. And the professionals in our field, I expect that they do share. So I know the embryologists are constantly sharing with each other what they're doing because they have long-standing relationships. Kind of like when Nam was at UCSF and I was at Einstein--we’d always talk about what each other was doing. So and, you know, all of us have peers and colleagues and other centers, so I have not seen that that much. I do think people are tied to their practices. I think maybe some of the older docs and we're a pretty young group, but maybe some of the older dots don't want to change the way they're doing it and that's what he's referring to. And so they say, “Oh, this is really special, because this is the way, I've always done it.” But I think most innovations have been pretty--it's hard to keep secrets in our field, you know, trade secrets, because our trade secrets are information and knowledge. For example, what I just shared with you on your podcast to everybody, I know nobody else is doing hypoxic ICSI. But I haven’t k been shy about that since we've opened that, you know, and maybe people will start doing it. You have to buy into something and believe that there's a benefit to it. But I don't think we're really secretive.
JONES 37:32
I see both sides. I definitely see enough examples of both--and perhaps you're right that there is an age difference. I think there's probably a practice structure difference. The people that I see sharing are the people that you mentioned, plus yourself, plus TJ--the people that are growing groups pretty quickly and adding a lot of new things tend to share. And then there are probably another class of folks that they want to hold on to their piece of their particular market. And I often find those folks are reluctant to talk to the folks across the street or have nice things to say about the folks across the street or are reluctant to meet with them or join some of the broader groups. And so--
KLATSKY 38:36
Embryologists do. And that's where--so if they're acting that way, that's what's silly. They may not be, but your embryologists are. When your nurses are at ASRM, they're sharing. And your junior docs who both went through fellowship together are sharing with each other. So that's where we try not to be--we try to have good collegiate relationships with everybody. And we always want it. And the great thing about our field is it doesn't stand still. So what is amazingly cutting edge today in five years, four years, maybe standard of care, and you'll have to continually move the needle. And that's where, like, to really, really keep growing, you're going to have to attract and keep the best people who all have that future in mind, you know, all want to move the field forward so we have better patient outcomes, so we can provide a better patient experience, and I guess that part you need to really give voice to your new hires. So that doc who is straight out of fellowship, hey, you know, maybe that's the person who's going to be Richard Scott or Bill Schoolcraft in 20 years. So listen to the suggestions that they have.
39:34 Dr. Mark Amols, Dr. Paul Magarelli, and Dr. Robert Kiltz…
JONES 39:38
So this concept of quality comes a lot when we're talking about the Affordable model. Dr. Amols, you mentioned earlier the Target model, the Walmart model, if we're thinking of just bringing something to bare at scale. And some people will say, well, Walmart that's not Saks Fifth Avenue, that's not Barney's, it's a lower quality in their mind. How do you respond to this issue of cost must be related to quality?
AMOLS 40:06
So I wanted to take a step back. So earlier you asked me, we talked about why I didn't think this model had taken off. I'm just talking from a business standpoint, when you see these CCRM’s down building on their stuff. From a business standpoint, I meant, I'm surprised it hasn't. When I use Walmart/Target example. I'm purely only talking about the example of volume. Okay? You're absolutely right when you said I think what you were asking earlier about the quality issue is that we're under the gun more than any other clinic. When the other clinic pays $15-20,000, amazingly, they get nothing out of that cycle. They walk away and go, Ah, this didn't work. They go to a clinic like mine, Dr. Kiltz, Dr. Magarelli’s, and they don't get through they go Oh, it's probably because it was lower cost. So we are really actually under the gun more than I think most clinics because we're always against that. And that's one of the reasons you rarely hear anybody say we're the cheapest. Our goal has never been to be the cheapest. We've been wanting to be affordable. And the definition of quality is if you're doing best practices, and as long as we're doing best practices, you know, I would consider us quality Now, one thing I want to talk about is, what got me into this actually is because my own personal IVF story. So my wife and I spent $20,000, my wife doesn't make many eggs. And so we had to go through IVF. And we spent a lot of money and we barely got pregnant, but we did. We were very fortunate. And it just was curious. I've always been a numbers person, I’ve always been a business mind, I wanted to figure out how much does it cost per IVF cycle? Why is there a difference in cost between clinics? And when I looked it up, what was surprising was it actually isn't that expensive. And so it's interesting, like your title is Secrets of the Affordable IVF Model. But really, there's not a secret. None of us are doing anything tricky. None of us are getting less. If anything, we're probably getting more than most clinics. We're just not overpriced. So when I first started and people said to me, You know what’s the trick? What are you doing? I said there's no trick, I just make less. And I'll even give you another thing that's really interesting about my client is that I love what they're doing. In fact, when I was going to start, I was scared to death I called up Dr. Magarelli and I said that I had this idea, I heard you're doing it. I'm scared to death, am I gonna go poor? Like what's gonna happen here and he told me, Don't worry, it's gonna go fine. It works. And so one of the things I wanted to do was, I actually want to be one of the top clinics in the country, meaning success rates. So if you look at all of us, you look at national rates, we're doing well, but we're-- the 2018--we’ll probably be in the top 10-15. So it has nothing to do with quality and anyone who says that is just saying that to distract from it. Again, we have some of the highest rates in the country. And yet we're a third the cost of the most of them. This is about all of us are in this for the same reason, which is we want to help more people. We want to be able, as you said, more accessibility for people who can't afford it. Dr. Kiltz said, and I agree hundred percent, there are people who come to us and say, “I would have never had a kid if it wasn't for you. I could never afford to go anywhere else.” And that's a great feeling when you know that someone who scrounged up from family members to make $5,000 and have a baby, it's a great feeling.
43:06 Dr. Matt Retzloff of Fertility Center of San Antonio…
JONES 43:10
So that's why I feel strongly about sub specializing. When I first started doing this--I belong to a group of other business development and marketing agency owners, and I constantly talk about subspecialize, subspecialize, niche, niche, niche and the resistance that I often get are people feel like it's limiting. And if my team was just doing this all the time--and it's like, you are just going deeper and deeper, and there is no bottom. So I've gone more into this than anybody and I still feel like you could fill the Staples Center with what I don't know. The first thing I ever figured out was, Oh, you can get a lot of word of mouth referrals from organic social media, that was the first thing. That does not always equate to a top-line spike in and of itself. There's everything along the way. And then you start to work on the next thing and the next thing, and you start to make it a system and that's how we approached the conversation with you all, but I'm very insistent that give me a business goal. Give me a business goal. Let me solve that with marketing and business. But don't give me a task list of we have to do this many social media posts this, this spend on Adwords--give me the business goal. If I'm accountable for it, make me accountable for it. And so I think that sometimes I turn people away from that because they just want to give people a checklist. You gave us a business goal. How did you feel about that process in terms of working towards a marketing goal versus working towards a business goal?
RETZLOFF 45:05
I do think they're, you know, really, they have to be tied together. And in one of our very first meetings, you don't sort of just break down with let's talk about the tasks, let's talk about the endpoint. And where do you all want to be? We talked about, you know, our five years strategic goals, 10 years strategic goals, where do we really want to be as a practice? And how does, how can the marketing tools be used to kind of reach whatever those goals are. And I would expect--obviously, I've just seen our sort of algorithm that you've come up with based on our goals--I can imagine that's not necessarily exactly the same for every practice. And, you know, it really has to be customized, based on whatever the unique goals or whatever the environment is for that particular practice. But I felt good that, you know, based on our goals, based on how you said we'd get from point A to point B, and have some metrics along the way that didn't just say, Hey, we're going to start now in next year, let's see if we got there. You said, Hey, every month, we're going to say, Hey, are we moving in the right direction, we got a green light, yellow light, or red light? And let's look at each of those areas and how we're going to kind of make all those green lights so that when we get to the endpoint, I mean, the process spoke for itself. We didn't even have to ask ourselves did we get here, you just look across, you got green lights, you made it. So the system kind of almost answered your questions real-time as you're moving forward, and you feel more comfortable and confident in the process. When you see those changes in real-time, and not just Hey, you're in a vacuum, you go off and say you're going to come back in a year and tell us we're going to be there.
46:49 Dr. Serena Chen and Dr. Roohi Jeelani...
JONES 46:52
This is something that I have not been able to get as many people as I would like to see the utility of media in this way of access, the patient's having access to them in some sort of scalable way. Because, again, we've moved mostly further away from marketing to new patients, but there still is all of this opportunity to move patients through the new patient journey that you just can't do in a half hour visit, because the patient is getting so much and to the extent that you can create more content, answer more questions wildly so that you have an educated patient with whom you have rapport and--
CHEN 47:34
Are connected to the practice--
JONES 47:36
And then you can customize 30-minute window. Is that what you're referring to, Roohi, when you're when you're--Is that part of the aim of your media strategy?
JEELANI 47:44
Yeah, exactly that because I think there's so many facets to advocacy and advocacy just doesn't necessarily mean what that--not to say narrow because I think that has a negative term to it,I think that's just the beginning of it--But yeah, advocating and multiple levels. But yes.
JONES 48:01
So I tried to use--we try to build systems where people can do that. There's some doctors that are just really good at doing it themselves. They do it whether or not their practice is involved at the practice level or not. There was a Social Media Panel last year at ASRM back in the good old days when we could all get together in person still and there was a Social Media Panel, both of you are on it and Dr. Crawford made the point of the patients that come to me that are familiar with me, because they've seen my content, are more likely to move to treatment or they're better patients because they trust me, they've been educated. I don't have any data on that, though. Do you both? What's your experience with that?
CHEN 48:45
I would love to have data, but I think we both have a tremendous amount of experience on it and it makes a huge difference.
JEELANI 48:52
Patient retention is so much higher. When they come in so well informed and so educated. One, like I literally have--what's the common trend, right? You see a patient, you put them through treatment, they have a negative pregnancy test, because not everything works. And then they go to somebody else. Because, you know, that it's just expected. I did that, I'll be the first one to admit I switched clinics. But with this, they know what I'm doing, why I did it. So one, they come to me with a negative test with, Hey, what are your thoughts on X, Y, and Z, it's more of a more of a relationship, you know, it's not like, I'm going to get up and leave you and let's figure out together because I know you tried your best. I mean, the amount I can tell you of messages that I get, like, I know you're doing your best, I know it's the same no matter where I go. So I want to stay with you, I really like you. And it's this relationship, that bond you have with your patients is insane. I mean, people will come from all over because they feel that they're connected to you.
CHEN 49:56
Yes, and this brings up two big pain points for you, Griffin that you're always talking about, is, you know, doctors don't want to do things like advocacy, and doctors don't want to do social media. And yet, these are tools that can help you in your practice that can connect you to patients in ways where you're not necessarily just sweating one patient at a time in your clinic, and spend you know, and trying to do just one patient at a time these kinds of activities--especially like the you know, the social media and education--putting a little bit of yourself out there does create relationships without necessarily just one person at a time the patients really appreciate when we share not only our knowledge, but you know, a little bit of personal stuff too. So that to show that we are human. And I think when a patient feels comfortable with you on that level, they are more likely to continue, they're more likely to feel hopeful. And I think we all know that in this age of tremendous technology where we can basically get everybody pregnant if they're open to treatment and they stick with it. The number one cause for not ending up with a baby in this field is the dropout rate. And I think we can address that through you know, through education awareness, advocacy, as well as create a better experience. If the physician is happier, it rubs off on the patient. That makes a difference for healthcare and for patients. So, I think it's a, you know, it's kind of a win win win--the whole package.
51:45 And Dr. Aimee Eyvazzedeh, the Egg Whisperer.
JONES 51:48
But what you said explicitly--I don't want Egg Whisper Clinics throughout the country, why not? Like--I get that the money isn't important to you. But why not for the period saying, you know what, there's a better way of doing this. And if I'm at the top, I can bring people in, have more control, we can impact more people with the way other people are doing, it just isn't as optimal as doing it this way. And I think that there's a whole crop of young doctors and nurses and potential staff that would want to buy into this, and we can help execute that for more people across the continent. So why so emphatic about I get the money. But why is it I don't want Egg Whisperer clinics throughout the country?
EYVAZZADEH 52:32
Well, I mean, if we can find a way to automate kindness and compassion and make it just ingrained in people, but like you said, everyone has different personalities. And the things that I hear other fertility doctors sometimes say to patients, it's like, mortifying, and it's like if someone had my name on their clinic, and patients were talked to in a way that was demeaning and degrading, I'd have a hard time with that. That would make me feel really, really bad. And so like, I've heard patients told, like, even if you had all the money in the world, you would never get pregnant with your own eggs and saying that to like, someone who's 34 years old, and then, you know, and of course, like people can say things, but who knows if that's what they were really told. But sometimes people actually use words like that, trying to get a message to a patient, and they think that that's the way to give them the message. But that's not the way to get people a message that makes people really angry and depressed and traumatized for like, years, I mean, like the patient who was told that like, she's still talking about it 10 years later. So, I mean, that's part of the reason is like I can't, it's really hard to have someone mirror my approach. And it's hard to teach if not impossible to teach. But through technology, there might be a way of using technology to make sure people like along the way, are getting what they need from a cycle without having like, necessarily all the human contact, and I'm hoping that maybe some something will come out of these ideas that I have.
JONES 53:48
That's interesting. Why is it very difficult and maybe even impossible to teach?
EYVAZZADEH 53:53
Because people don't want people texting them. Like, I could probably go to my phone right now and I'll have five text messages. And I tell my patients, I used to tell them, I'm like herpes, you know, I never go away. And what I mean by that is, once they're pregnant, I always want them to know that I'm here for them. And now I tell them, I'm like your luggage, you always know where I am in your house, so if you ever need me, you know where I am. So please reach out to me and I love getting updates from patients throughout their pregnancy, I consider every pregnancy and angriness and that your pregnancy is a VIP. And now more than ever, it is so important that my IVF patients get the best prenatal care, because as you've heard, there is an increase in stillbirth right now going on through this pandemic. And I think a lot of that has to do with telemedicine and not seeing patients face-to-face. And I think IVF patients are at higher risk of, you know, some things happening, especially in the third trimester, especially in patients who are over a certain age. So I feel like that by staying connected to my patients, if they ever need something, I can advocate for them if they need me to advocate for them. So, you know, that's not something that a lot of people will do. I know there are physicians out there that do that. But there's just a handful of us.
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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.