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
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.