INSIDE REPRODUCTIVE HEALTH PODCAST
Ep. # 33 - Building Consensus in a Multi-Partner Physician Practice: An Interview with Louis Weckstein, M.D.
Growing your practice is exciting and adding in new Physician Partners can mean a lot for both your business and your patients. But adding to your group of decision makers can be intimidating. In this episode, Griffin Jones talks to Dr. Louis Weckstein, Medical and IVF Director and Managing Partner at the Reproductive Science Center of the Bay Area in San Francisco. Dr. Weckstein discusses the importance of building consensus amongst Managing Physicians and three simple ways to help facilitate easier decision making.
Welcome to Inside Reproductive Health, the shoptalk of the fertility field. Here, you'll hear authentic and unscripted conversations about practice management, patient relations, and business development from the most forward-thinking experts in our field.
Wall Street and Silicon Valley both want your patients, but there is a plan if you're willing to take action. Visit fertilitybridge.com to learn about the first piece of building a Fertility Marketing System--The Goal and Competitive Diagnostic. Now, here's the founder of Fertility Bridge and the host of inside Reproductive Health, Griffin Jones.
GRIFFIN JONES: My guest on Inside Reproductive Health today is one of those that did not go right into REI Fellowship directly after his OB/GYN residency. Dr. Weckstein did his OB/GYN residency at University of California-Irvine. He established a successful OB/GYN private practice in Southern California in 1984, but he found that infertility was his passion. We've returned to UC Irvine for his REI fellowship training in 1987. Dr. Weckstein served on the board of directors of PCRS--the Pacific Coast Reproductive Society--and it was a past California representative to the National Advisory Council of ASRM. He's authored more than 50 publications and abstracts with focus on IVF and egg donation. He serves as a special reviewer for fertility and sterility and he has served as Medical Director, IVF Directorate of the Reproductive Science Center of the Bay Area--RSC in San Francisco area--as well as its Managing Partner since 1997 and that's what we're going to talk about today. Dr. Weckstein, Lou, welcome to Inside Reproductive Health.
LOUIS WECKSTEIN: Glad to be with you Griffin. I've listened to some of your podcasts and happy to be joining you.
JONES: I want to start with this little notion that I pulled out from the bio which is that you weren't one of the Founding Partners. It sounds like you joined some others and then became its Managing Partner. So you can you talk about what the practice looked like before you joined it? Who did you join up with and why?
WECKSTEIN: Yes, I when I came out of fellowship, I stayed on at UC-Irvine for a couple years and then was drawn to the San Francisco Bay area. And when I was looking around for infertility practices, I joined two other doctors who were in practice doing a fair amount of IVF and general infertility. And when I came to the practice, they were older doctors and well-established, really good doctors, but they appreciated some of the new techniques and information that I brought to the practice and it was a very successful endeavor joining them.
JONES: So you became the Managing Partner--at what point does that happen? Because I think we often think of the Founding Physician, if there's one or sometimes there's two, one of those people would be the Managing Partner--it seems to usually play out as. That isn't the case for you all. How did you become Managing Partner at you were the third to the game?
WECKSTEIN: I think it just evolved over a period of three or four years after I joined. And I think part of it was interest that I had in bringing new things to the practice and managing the practice from a business, as well as a medical standpoint. After we were working together for a while it was just a natural thing that they turned to me and wanted me to take over on some of those duties and it evolved in that direction.
JONES: Well, let's talk about what it means as well, because one of my concerns for the field--for independent practices or for smaller practices or--any model where there might be four to seven, somewhere in that ballpark equal decision-makers--is that there's not one person who's necessarily steering the ship. And when people express concerns of consolidation to me, one of the concerns that I have is this. Now that you have these enterprises, these entrepreneurial endeavors, that are steered by one captain with a vision, with measurables to work--what accomplishing that vision looks like and it's someone's job to make sure that's all achieved. Whereas, I think we've inherited the model of the 20th century general medical practice where there's a practitioner who opens up a practice and hires an office manager and that is the business. Many of our independent practices are on that model now against these models coming from Wall Street or Silicon Valley that are corporate enterprises with an executive at the helm--there isn't a Managing Partner. You're somewhere on that sliding scale. What is the managing partner do?
WECKSTEIN: For us, I think once again, it's really evolved over time based on the size of our practice both in terms of the number of physicians, as well as the number of patients that we see. I think the Managing Partner will spend a lot of time with the so-called Executive Director in our practice, working together to fulfill the vision direction that all the partners together have gotten together and decided on. In our practice myself, as well as our Executive Director, will meet weekly and talk about many of the issues and try to keep the practice moving forward in the direction that we've been given from the shareholders, the Partners in the practice.
JONES: So, you’re meeting weekly with the Executive Director. Are the other partners also meeting together? Are you all meeting weekly with the Executive Director? Or just you as the Managing Partner?
WECKSTEIN: I think one of the keys to our practice functioning well has been meetings. You know, on the one hand, I dread meetings, on the other hand, I think it's really important for communication and consistency. So we have a number of meetings at our practice. One of those is the weekly meeting that I have with the Executive Director and it's usually just the two of us and we'll spend typically an hour and a half. But in addition to that, we have a notorious Monday evening meeting that typically can last from 5 p.m. until 7:30 or 8 p.m. every Monday. And each of those Mondays, we alternate what we do. So, the first Monday of the month is a meeting with the Partners, as well as the Executive Director and we speak about business topics and important things to the practice from that standpoint. The second Monday is all the Physicians together talking about clinical topics, such as a Journal Club, case presentations about patients, discussions about things that need to change in the practice. The third Monday is all the Physicians with the administrative team and that includes the Executive Director, the IVF Lab Director, the HR Director, Business Office Supervisor, Clinical Operations person, and Business Development or Marketing person. This is the meeting that I think is really key where there's a lot of communication from those administrative team leaders to the Physicians and back and forth. And that way everybody knows what's going on in the practice at different times. It's not a surprise that such and such person is leaving or this is a decision that's been carried out. So that's the third Monday of the month. And then the fourth Monday is the IVF Lab Director, and sometimes some of the other staff, with all the Physicians to go through metrics in the IVF laboratory, pregnancy rates, as well as changes that are going to be enacted in the lab. So those meetings we found they’re really critical, and I think one of the big keys to the successful running of our practice.
JONES: Totally agree with you. I think in terms of meetings, the meetings that I dread are bad meetings, which is why I have such a reputation for being such a stickler about meetings. And anyone in any of my mastermind groups that’s listening knows that--they’re probably laughing because I'm strict about when the meeting starts, strict about when the meeting ends. I do not like a lot of small talk, a little small talk in the in the segue part, I've got reserved five minutes for good news so that we have that building, and then it's let's get into the meat of it. And if we're not leaving with something being solved, or a clear plan for something being solved, in my opinion, it's a waste of a meeting. So, I think they’re extremely productive when they have a purpose, and there’s boundaries. I’ve also worked in environments where we have meetings for the sake of meetings to avoid doing work, and I don’t think that’s respectful of anyone’s time. You've outlined for per month, which is more than I think some practices have here. You have four per month, they’re every Monday, you have different themes for them. One you talked about is business, which is the first Monday of the month. Third is administrative. Can you talk a little bit about the difference of business and administrative in this sense? Is one being health and long-term decision making of the business and the other is more operations?
WECKSTEIN: Yes, that's exactly right. There's often business decisions that might be not necessary to involve everybody in the practice--all the administrative team, maybe all the employed Physicians--things such as budget issues, you know, what areas do we want to focus in developing our practice? Do we need more Physicians? Do we need another office? Things like that. So those are the topics that are typically covered at that first “business meeting.” That's also another area that I think, on a bigger level, can be discussed with a strategic planning meeting and we try to have these yearly--typically in the first quarter of the year. We work on both short-term--maybe one to three year--and more long-term goals for the practice--priorities. Then outside of that meeting, once we really establish what those priorities are for those periods of time, we'll work on the details of how to accomplish those priorities and divide up into smaller groups and then get back to the big group. Sometimes at these Monday night meetings--these first Monday of the month business meetings--to talk about what we've accomplished in moving forward in those directions, what additional input that will need. We try to keep coming back to those items that we've identified in the strategic planning meeting--the annual meeting--at some of the Monday night business meeting in order to make sure we’re really following through. Too often, those details make great plans and you don't follow through on those plans.
JONES: So you've got the mechanisms for both the direction and goals of being set at the beginning of the year--that's a strategic leadership meeting, a strategic planning meeting. Is that off-site?
WECKSTEIN: Sometimes it's off-site. Sometimes it's on-site. It depends on how easy it is for us to get away from the practice on a weekend with all the Physicians, if they're going to be attending.
JONES: Do you find it you cheat a little bit if it isn't off-site? If you do have it at the practice, if somebody gets called in for a call or there's something going on in the lab that the Lab Director wants to talk about? Or any number of different springs that might come up?
WECKSTEIN: In the beginning we found that that was the case. I think over time, we've been able to be disciplined enough that that's not the case. I think, again, some of the advantages of doing it on site is we can get even the physician who's working that weekend, they at least will be able to come to the meeting a little bit later on.
JONES: So you're setting the direction goal beginning the year, you're touching base on it every month, is this also where you just make sure that everyone is on the same page? Because, Lou, I'm not joking when I say that I have clients start with me where one partner will say to me, “Okay, but I want to talk to you over here.” And another partner says, “I want to talk to you over here.” And I say, “Gentleman--sometimes it's ladies, but usually it’s gentlemen--gentlemen, let's all get in the same room and flesh this out because--” And we're just an expert Client Services Agency--we're not even an employee or a partner. But what I often find is that, if we were to start and in any kind of engagement without everyone who is going to have buy-in, they’re buy-in from the beginning, then four month in, five months in, is that person creeps in and they've got a different picture in mind and really rocks whatever results we've accomplished or I'm going to accomplish. So now it's just part of the process that we do in the beginning, is we make sure that everyone is on the same page. Do you find ourselves setting and resetting expectations amongst yourself in those first of the month Monday meetings?
WECKSTEIN: Yes, I can't agree with you more. I think getting that consensus is key and when we have discussions around important plans in the practice, of course, there's often disagreements on different aspects of things, but we'll keep hashing things out until we get that consensus and buy-in literally from everybody. I will say that we don't have to vote in our practice. We end up being able to reach consensus. It's not always simple, but we reach consensus--people will compromise. And I think once we get that consensus, everybody is committed to then following through along those lines. It may sound cliche, but I think we've been able to do that, and it's helped a lot in being able to keep the practice moving forward.
JONES: You’re at a practice size where it made sense for you all to hire an Executive Director. Sometimes in a practice that’s even larger, there's more offices, more Physicians, that Executive Director becomes a Chief Executive Officer. How did you make that decision to hire that person and how did they end up there? What is their dynamic like with the owner positions?
WECKSTEIN: I think that's also been something that's clearly evolved over time. As you said based on the size of the practice, you know, starting out with three physicians and a “Practice Manager,” and then over time seeing that what we needed was somebody more than that. The position is certainly evolved a lot over the last 20+ years. Currently, we've had the same Executive Director for the last 10+ years and that's been another key to the practice. He understands all the Physicians--the different personalities--very well, what we each need to be comfortable with, and we've been able to reach really good understanding with that person so that we don't need to micromanage what he's doing. Over time, we can just let him fly with certain things and he’ll always report back to us or ask us questions if he's unsure about how we want to move forward. But I think certainly, as you said, as the practice grows, you need somebody who can do more of the big picture things and help to, again, keep the practice moving forward.
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JONES: For those that may just have a Practice Manager or an Office Manager right now, in your mind, what is the difference between a Practice Manager or Practice Administrator and an Executive Director?
WECKSTEIN: I think the Executive Director can really handle virtually everything is my experience. From helping you with contracting to a lot of the business aspects--financial aspects of the practice--to bringing in new partners to managing staff and managing physicians. I don't know that there's a specific delineation between the two, but I think as the practice grows you certainly need somebody who is able to do more.
JONES: I think that we probably worked with some practices that are at this point where an Executive Director would make sense for them. Usually when we start to see an Executive Director, it's somewhere north of--somewhere around that 7/8 physician mark is often when they'll have an Executive Director in place. Often when I might encounter five physician groups--they may be still in that 4/5 physician group--they still have that Practice Manager. That’s where I would see the need for an Executive Director start to come in. For our listeners that are thinking about this and they're not sure when or where, where do you see that--either volume or number of Physicians? Where does it make sense to start to look for an Executive Director?
WECKSTEIN: I think you're right. I think somewhere around that 6/7 physician. I think probably a part of it depends on how many offices you have, how many staff you have, what volume you do. And also what interest the partners have in taking care of a lot of these things themselves versus really wanting to spend more time on the medical aspects of things and wanting to have somebody else help even more with some of the bigger picture items and business things. So it probably varies a little bit from group to group.
JONES: I think there's a number of other decisions that you have to make both when you're hiring this person. And when you are a multi-Physician Partner group, another big question that comes up is having a Managing Partner in the form of a large Fertility Network, either through a contractual agreement where they're Managing Partners in some sort of fee, sometimes, it's equity. You all have had that conversation and taken some of that route. How do you make that decision as a group together?
WECKSTEIN: I think in our practice, a lot has just evolved over time. We try to divide up a lot of the duties and have physician champions in different areas because you know, certainly one person can't do everything. So in our practice, we have a “Medical Director” and “IVF Director,” a Managing Partner, a champion for Business Development or Marketing--and these are all from the partners in the practice--a champion who works on IT/website/social media, a physician champion who works on third-party reproduction, surgery in our practice. So we try to divide it up and I think we've had discussions over time based on who is interested in each of these areas and taking it on, and also who might be good in these areas. And by discussing that amongst the group, things have evolved. At times we’ve made changes and often people have kept with that position for quite a few years and it's worked out well.
JONES: But when it comes time to selling part of the practice or making a big decision of a 20-year contract with somebody. If and when it ever comes time to sell Fertility Bridge, that decision is a hundred percent mine. I have to take into consideration my employees, and what I want to do, but there isn't someone else that I'm also selling their share when that decision comes time. And this is something that a lot of our listeners asked about we talked about before on show. I've had John Storment who talked about it before and he said he did consider his Partners. They weren't other co-owners if I understood him correctly, he made that decision himself. When there are other Physicians that own the practice, how do you make that decision together to sell part of the practice or part of lab?
WECKSTEIN: For us in our practice currently, we have Physician Partners as well as non-Partners, who the goal is for them to be and they're all on the partnership track so that they can ultimately become a partner, but when there's a major decision like that--potentially selling part of the practice or making big decisions--those are all made by the Physician Partners. I think we've--once again I mentioned earlier--that we haven't had to vote on things. So even on some of these really big items, we've been able to hash it out--the partners in the practice--and come to consensus and make decisions and I'm certain that doesn't work in every group. And a lot of times things might come down to, “Okay, how many shares I own and people who own more shares have more say in the vote,” and I think that's how our business documents are actually set up, but we really try hard to just reach consensus and have been able to do that. I think by doing that, there's less hard feelings after some of these decisions are made.
JONES: That consensus to me is amazing. Do you think that going for this consensus, for practices or companies in the field that large, slows us down to a point where we're at some level of risk? If I look at most quickly growing practices in the country, it's usually a single Physician-Owner who has been really good at delegating. It might have other Equity Partners, but it's clearly the lead in this case, the visionary in that role, or some of the--I won’t name in my name, but--some of the egg freezing companies or some of the newer companies that are clearly driven to capture the millennial demographic, they’re often led by one executive. They don’t necessarily have to gain consensus. They have to gain buy-in from their team, but that’s different. I know, because I don’t have to gain consensus. I have to make the ultimate decision. I need my team to buy-in to it, if they don't then there’s either personnel decisions or I'm not doing something correctly, but it's not the same as building consensus. Do you ever worry that consensus will slow us down too much?
WECKSTEIN: I agree with you. I think it can particularly as you get to be a larger and larger group--or larger and larger group of Partners. I think at some point in time, maybe you can’t have all the partners having the same vote. Maybe you have to have--and we've talked about this over the years--a board or smaller group amongst those Partners to make some of these decisions. But I think difficulty--just thinking about it for the first time now as you mention it-- in terms of being able to make quick decisions, having one person being able to move a company forward is, will that be long-lasting? Will it work over a significant period of time? I think if you can build consensus amongst a group, I think it's more likely that people will stay engaged and be brought into the practice for perpetuity or at least for a long period of time. Maybe some of it has to do with the people who have joined our practice as partners, but somehow we've been able to get that, maintain that, and I think that's been part of the key to success with our practice over time.
JONES: Remind us how many Physician Partners and how many physicians total are you at right now?
WECKSTEIN: We have five Physician Partners and seven total Physicians.
JONES: So that to me, by being able to build consensus that quickly, and have a group that size, sometimes I see two Physician Partners that can't get to consensus that well. You've given us three actionable things that practices can do to build consensus, to move more quickly, and to get on the same page. One is to meet every month--and in your case, meet four times a month, but you meet about business just once a month. A second is to have a strategic planning meeting--that could be on-site or could be off-site--once a year. And third is to hire an Executive Director. And across these three things, you have five Physician Partners, you have to do new Physicians, you haven't had to take a vote, and you've done some major serious things, like join an Infertility Network, like hire new doctors, and hired an Executive Director--you've had that Executive Director for 10 years, you haven’t had to take a vote. You've been able to arrive at consensus--to me, that's indicative that you're just with your people. And so if you can have that type of energy where people are able to come to consensus without a vote, and have people for that long, how do you make sure that as you're bringing new people in--that you were number three, two more came after you, there's two more positions that that might be in their future--how do you make sure that you are making sure, under no uncertain terms, that this is just who we are, this is our culture, this is how we operate, so that you're not threatening that consensus and energy that you have now?
WECKSTEIN: I think it's a great question. I think you know, what do you look for when you're trying to bring a new physician to the practice is key. I think you know, are they interested in more academics versus Private Practice mentality? Do they have a solo mentality--do they want to make the decisions call the shots or can they be part of the team? What is their work ethic? All those things are really important, and I think we try to have potential new doctors meet with, hopefully, all of the physicians in our practice and sometimes that's done by video conferencing, but most of the time it's done by them actually being able to meet with all the Physicians, sometimes come back for a second meeting. We really talk about the culture in our practice and really try to get a feel for, are they somebody who can be part of that culture? And over the years when we've looked for new Physicians, have been a number of times that even though we've had a lot of candidates, we decided none of them have been right to fit in with our practice and even though we really want another doctor, we'll wait another year. And I think that's helped a lot to be able to continue with the similar mentality.
JONES: I think when you say that you had the good fortune of being able to just pass over some candidates that weren't a good fit, there might be some folks listening in other parts of the country and think, “Yeah, says the guy in San Francisco. Must be pretty nice to be able to turn away REI candidates.” I think there are a lot of places in the country where it is so hard to find an REI. There are so many small markets in the interior of the country where--can't say this is a general rule-- but if someone isn't from that area, there's almost no chance of them recruiting to that area. Do you still give them the same advice that just no matter how long it takes, that you wait until they find that right fit? Or do you have the privilege of being more discerning because of where you are?
WECKSTEIN: I think you're absolutely right. It's gotten harder and harder as there are fewer and fewer doctors coming out of fellowship and we certainly had a more difficult time finding the exact right person in more recent years. I think if you're at a point in time in your practice where you really need somebody, you may not be able to be as picky, but hopefully then you can make sure that the person coming in knows that there's a--whatever your period of time--three year partnership track period to really get to know each other to make sure that they're the right person. And if they're not, as difficult as it is, I think in some ways it's better to part ways earlier on than to get into a situation where you'll all be fighting later on.
JONES: And maybe in line with that is if you do find that right person, probably take it seriously because I think that I've seen that. I can think of six doctors in the last six months or so that left their groups--and these are typically docs in their early 40s late 30s, sometimes it's their job right out of fellowship, sometimes they were in Academia for a little bit, then they went into private practice for two or three years--it's right around that two or three-year mark where they think that they're on a partnership track or the partner wants them to be, but for whatever reason, expectations are not the same and end up leaving before they end up becoming Partners. So I think that if that's the case--and I did have someone that we were consulting with in a smaller market, and he said he was looking at someone and I said, “Well, is she like this? Is she-” “Oh, yeah, she's great.” And I said--we'll call the person Joe for this conversation--said, “Joe, put a ring on it. Let's get into a position where this person can be on a track because you want to retire in five years. You're in this small market in this part of the country, another one's not necessarily coming around in the next few years. And so, when you do find those people--you talked about having them meet the team--but how do you make sure that that one, they're serious about being partners, but also that you're conveying to them that you want them to be partners?
WECKSTEIN: Yes. I certainly agree with you. You know, you've got to be--I think the number one thing is you've got to be transparent to new partners. They have to understand before they come in, what it's going to take to be part of your group from a financial standpoint, from a working ethic, coverage call time period, and let them know what they might ultimately earn in a practice once they were a partner in the practice, and being very fair to them, because I think, as you said, there are there are more jobs available than there are candidates. So if you find somebody good you want to take good care of them and keep checking in with them. I think to have annual reviews. Early on, I think it's really important to do good mentoring for new REIs coming out. Some of them have been trained in very large programs where they have a lot of experience, others in smaller programs. And I think being able to do that mentoring, offering them the consultation with other physicians in our practice--we talk at each of our Monday night meetings about clinical things, even when there's other topics about clinical cases, we email the group all the time. And so that younger physician coming in has to feel that they have the support of the group from a clinical standpoint, and also from a, “We really appreciate you, we want you to be part of the group. You need to have your time off. You need to have your work-life balance, and hopefully, if you maintain as part of the group, you're going to be rewarded for that.”
JONES: You've given us so much to talk about with partner expectations, with making decisions as a group. Three ways that I want to retouch--three very concrete ways--that small, midsize, even large practices can get on the same page is to: One, meet at least monthly about business in your case, you meet weekly on different themes of meeting. Regularly--let’s call at least once a month--about business. Having a strategic planning meeting that's on-site or off-site once a year. And hiring an Executive Director. You’ve given us a lot of experience to consider. In conclusion, what thoughts would you want to say--about either concerns or aspirations--that you have for the field in the next 5 to 10 years?
WECKSTEIN: Before I do that, let me throw out one more thing that I really wanted to emphasize that I think is unique to REI practices, and that's you've got to--I think you have to include your IVF Lab Director in a lot of these decisions, in a lot of these meetings and discussions, and getting buy-in from the IVF Lab Director in your vision, working with the IVF Lab Director and the IVF Lab Staff, as part of the team. I think often there's a us versus them--or there has been for many years--us versus them mentality. Something's not working great in terms of pregnancy rates or embryos, and it's your fault. It's your fault. You really got to get that buy-in and work closely together with the IVF lab and the IVF Lab Director. So I just wanted to make sure I threw that in there, and we've been very fortunate to have a great IVF Lab Director for the last 25+ years.
As far as excitement for the future, we in this field are really fortunate that we get to work with patients who we can make such a difference in their lives. And I think it's very rare to find a doctor in our field who doesn't really enjoy what they do. I think the new technologies that are coming out all the time in our field--thinking about the changes that have occurred from transferring embryos after two days of growth and having 20% pregnancy rates the blastocyst stage and PGT--all these new changes that I've seen over time are very exciting and continue to look forward to. As far as concerns, I think one of the biggest things for me is not having the contact with patients because of EMR. I think the EMR has really taken us away a lot from talking with patients directly, and I think it's important to maintain that contact with patients and I hope that will come to a better way in the future, so that the EMR does not dominate so many of our lives.
JONES: Now that means I hope to be seeing you on a lot of Instagram posts, so we can see more of your face and your patients can interact more with you that way!
WECKSTEIN: Thanks Griffin. That sounds great.
JONES: Thanks so much for coming on Inside Reproductive Health, Dr. Weckstein.
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.