Ep. #38 - Building Community: The Rise of Instagram Among REIs, Dr. Candice Perfetto

Growing your followers on social media can be challenging, especially when your niche is focused on fertility. On this episode of Inside Reproductive Health, Griffin Jones, founder of Fertility Bridge, talks to Dr. Candice Perfetto, a board-certified REI working in Houston, Texas. Dr. Perfetto has grown her following on Instagram to over 10,000 followers and has seen the effort carry over into her practice. She discusses why she got started on Instagram and how she uses social media to build relationships with other practitioners and patients, both near and far. You can find Candice on Instagram at @candiceperfettomd.

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 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: Today on the show, I am joined by Dr. Candice O’Hern Perfetto. Dr. Perfetto completed her fellowship training in REI at Stanford University. She went to medical school at Georgetown. She was the Chief President of Obstetrics and Gynecology at George Washington University, also in DC. Dr. Perfetto is committed to patient-centered care. You can see her sharing content and ideas about that on social media. She is board-certified in both REI and OB/GYN. She has experience in all areas of infertility; her special interests include recurrent pregnancy loss, oocyte preservation, and improving treatment outcomes. She now practices at the Center of Reproductive Medicine in Houston, Texas. Dr. Perfetto, Candice, welcome to Inside Reproductive Health.

CANDICE PERFETTO: Thank you for having me today!

JONES: This is the first time we've met’ we’ve followed each other on social media. No small part of the reason why I wanted to have you on the show is because you have these interests such as recurrent pregnancy loss, egg freezing, improving outcomes. And when someone has these interests, it’s ok, how do I communicate these to the patient community? How do I collaborate with my peers? And for years, that just meant maybe go to some meetings, maybe do a couple talks at OB/GYN offices, and now there is a class of REIs who are just reaching the masses, almost, on social media--at least tens of thousands of people collectively, every single week. And it amazes me how someone that just finished fellowship five years ago can come on reach the number of people that you have, and build that type of rapport with the patient base. And now I'm starting to see like almost two different kinds of REIs basically based on how prevalent this is. But maybe, we could start with, was that something that was intentional for you? Where you already Instagram before you even went into to fellowship? Was it something that you are just on personally? How did it become a tool that you connect with other doctors and with patients?

PERFETTO: So actually, I am a pretty private person. So I was not even on Facebook until I think two thousand and maybe 16? When everybody else was getting off, I sort of finally jumped on.

JONES: Well, welcome!

PERFETTO: Yeah! I jumped on and I was really just to catch up with people that I had not seen in forever. So I had very little personal self on any type of social media. I decided to jump on Instagram about a year and a half ago because, to be honest, I was actually doing it for more of a marketing--to try and meet new patient and get myself out there, and really kind of show myself to, like, the public. I do think that I'm a pretty caring doctor. I think I follow evidence-based medicine and sometimes, in a really big city such as Houston, you kind of get lost in the other dozens of doctors that are out there. So that's why I jumped on about six, not even six weeks into it, I saw that there was so much more potential Beyond just marketing myself. That really I could use it as a really broad platform to educate women and to educate the general public on fertility, and infertility, and trying to conceive, and Women's Health, and then even as much as a few weeks ago, I have sort of taken a whole new approach that it's not just about fertility and Women's Health, it's also about personal growth. So I have definitely, in the year and a half, seeing major changes to what I post and the general thought process is to really just be an educator and somebody who inspires the women out there.

JONES: So there was no social media in your life prior to 2016?

PERFETTO:Very, very limited. It's really sad.

JONES: How did your strategy change from maybe it’s just marketing, maybe it’s just getting my name out there. To me, what you're doing now is marketing, meaning just you're getting ideas out there. You're helping people, you're connecting with people--to me that is marketing. But it sounds like you had a different vision for it then you do now. What's changed in the types of content that you share?

PERFETTO: So when I initially started, I was way more focused on sort of my practice. And I think my practice is awesome. I think--and I’m going to be blunt--I think we're the best in the city. And so, I was really interested in sort of introducing people to our practice because our central location was, or still is, in Clear Lake, but I'm actually in the heart of the medical center. So I was just really wanting to sort of introduce my practice. And then I started to see that patients and followers really wanted to know more about me as the doctor and and less about my practice. And although I was still marketing for practice, I was really just sort of introducing people more of myself.

JONES: And now it’s come to be--I look at a few of your posts from this week, and a lot of the people that you're interacting with other doctors, but a lot of there's a lot of peer collaboration, discussion, but also people are coming on and just ask questions about PCOS, or asking questions about egg freezing. You look at different posts that you have, people just jumping with questions and you answer them! And so do you see that startingto to make its way for people that are new patients and they’ve built that rapport because you answered some questions four months back, or you connected with them on a post? Or are those two worlds still kind of disconnected?

PERFETTO: So first of all, there is an amazing medical community out there. So I have connected with so many other reproductive endocrinologists that I have never even met, but I've connected through Instagram and they are a great source of knowledge and networking. So that has been--if I had nothing else, that alone has been great. From the follower and patient perspective, the other kind of questions and posts I get, I do get a lot of questions. I regularly have to remind people I cannot give medical advice, but I do like to give just general knowledge. I think that general knowledge is something that a lot of people are lacking, either they're lacking it because they don't go to their own doctor, or they're lacking it because they feel like, unfortunately, their doctor doesn't have enough time to really go into the deep dark depths of PCOS or endometriosis. So I like that somebody can refer back to one of my posts and get a little bit deeper information then they maybe get with that 5-10 minutes that they have with their General OB/GYN or even their primary care doctor.

JONES: And it’s general knowledge, but it's delivered in a personalized way. It’s not personal to anyone’s case, it's not about a case, it’s not medical advice, but it's a comment on a social media post. If someone can connect with it more intimately and readily than I think just reading an article somewhere. And there's yourself and probably a dozen doctors in our field, there's several hundred thousands more in other subspecialties, in specialties and in general health and wellness that are corresponding with patients in this way. It’s just become the norm and I think it's become the norm just in the past couple of years. I think people were terrified in the beginning of sharing in almost any kind of way because the words social media appears in HIPAA legislation exactly zero times. There's no guidance from Health and Human Services, there’s no guidance from OCR, and it's just such an antiquated piece of legislation that one could even and--one could strictly argue in such a way that even having a Google My Business listing claimed without even any responses could could have violations for PHI. And people were paralyzed by that for a while. And now, those thousands of doctors all over Instagram, Facebook, this is the norm. It’s almost as though we’ve got our own code for this. We know how to give medical advice or not to mention cases. But what do you think? Well, why do you think that is? Is it just the fact that the younger generation that’s just more comfortable with this? And prior cohort maybe just saw it as something completely new, so it could only be a risk? Why do you think that this is--there's definitely been a shift in the sands in the last two to three years.

PERFETTO: I mean I still worry about HIPAA. I mean, I think all of us do. I'm overly cautious about what I post. It’s definitely in the back of my mind, but I also think that the younger physicians--and I don't really even think I'm all that much younger--but the one's closer to millennials and the ones who are millennials are more at ease with using social media. Like I said, it was a jump for me to even start a Facebook page back when I did. So this has been a major shift in the way I think of things, but I do think that there's so much of medicine that is not getting out to the masses. And if physicians who practice evidence-based medicine who can be on social media and feel comfortable with it, are educating people. Then if you're just giving general basic knowledge, you're really not putting yourself at risk or certainly not too much risk.

JONES: I just don’t see how over time, there's any way that physicians that aren’t using these platforms are able to compete with those that have really mastered them. Other than there's just the caseloads are so high that there's so much to go around for everyone, but they're the ones getting what’s leftover. And I wrote an article years ago, apparently before you were even on Facebook! I wrote it in 2015 or 2016, and I said, “Guys, it’s Instagram. I promise, it’s Instagram.”

PERFETTO: That’s what brought me on! Your article brought me on!

JONES: Never let the truth get in the way of a good story! That’s the one thing I tell people. And what I was hoping was that my clients, our prospective clients, that they would really embrace that. That, yeah, let's communicate with the patients. That’s generally not what happened. They really didn't. I mean they are on Instagram, but that is really in many cases, just checking a box. They've got somebody just kind of doing really generic posts. What I have seen is people like yourself, and I can think of a dozen people or less, almost all of whom are in their forties or younger--with the exception of one or two--and actually when we were looking at doing a virtual conference this year, and we’re looking at what the doctors that are influencing on social media--all of them female. There are many who are using it, but those who are really leading, who are really being influencers. I wonder if this is about the potential for divide one, by gender, but also, it certainly by age?

PERFETTO: Definitely and I would say it's kind of funny that you're bringing this up because really recently one of the OB/GYNs that I follow just posted about an article that was published in the Journal of Surgery on how social media is a great place for women to meet mentors in surgery. And I think that we make ourselves more available on these types of platforms, which is great for the younger generation because if you're in a large surgical field--less so is REI because we are pretty half and half female and male--but if you're in a large surgical field, and you don't have a lot of women to look up to you, can go to Instagram and find somebody to be your mentor. So I think women, in general, probably feel a little bit more comfortable with it. I would say, also there are more younger--from a fertility perspective--a lot of the younger doctors that are graduating from fellowship are women and a lot of the older doctors that have been around a lot longer are men. I mean just how the field started. It was much more male-dominated and now it's becoming a little bit more female-dominated. So you're going to just naturally get that more females because we're also going to be a little bit on the younger side. To go back to what you were saying also, about doctors who aren’t on social media sort of getting the “leftovers,” I would say to some extent, yes. In a big city, I think that it's going to be pretty vital to be on social media because the public is on it and they're going to be looking at their doctors before. But I would also say that if you're in a smaller city, you're probably not going to have as much competition, so you kind of go to who is available. But I'll also say that I see a lot of complicated patients now. So I get a lot of patients coming in even from other states, like patients coming in from Oklahoma or their cities, like people coming in from Austin who want a second opinion because they found me through social media. They want me to try something different, something special. So I do see more new patients, but I also see more complicated patients because of it.

JONES: I’m glad you brought up the smaller city example because I can think of something--and I talk about the smaller city examples often because it is the small practices or independent practices in smaller cities that invest the least in patient experience. That's always true, we do work with people who really take it seriously. But, I do see that some people want to advance because that's in their nature, and other people advance just because they have to and the pressure is on them. And that’s the case in a lot of large cities and it's less the case in smaller cities. But I can think of an example--and I just want to be careful about what I say because I really like all of the people involved--but there's a group that had done very well with social media marketing, we worked with them for a long time. They just got to a point where they were good and our company grew and they were good at the level they were at. And I was trying to say that this isn't something that you are just good at and then it is done with. This is the advancement of technology, of communication, of society, it’s something that's ongoing. And they were satisfied with that. One of the doctors left, began their own practice. And this doctor I’m not seeing on social media and this doctor's going after it! And the other group has regressed to just sort of the tactics of posting a meme or posting just an infographic and I just think, “Yeah, it is not long before this person takes a lot of that patient load.” In a way that it's not just knocking on the doors of the OB/GYN offices, maybe this person is doing that too, but this is a way of now you’re capturing so many people that this practice has abdicated and I just see that as such a liability.

PERFETTO: I totally agree. I think one of the things also is that most of the doctors on Instagram--because that's really the biggest platform for from medicine, I would say--are themselves, they are not even their practice. So I mean one of the risks is that doctor could go to a different practice, and the patients would follow that doctor, not necessarily the practice. So I think that example is a perfect example of that. But it's doctor-centered more so than practice-centered, but I also think patients really like that. I would know if my doctor was not posting. Much like I can tell but all of the fertility doctors that are on there, are posting. They don't have somebody posting for them. They don't have send me your responding for them. I spend minutes between each patient responding to posts. I spend 30 minutes before I go to bed responding to posts and looking at DMs. And I think that’s what the majority, if not all of us, are doing because the real connection is between the actual physician and the follower or the physician and the patient, not between somebody who's doing it for you. And when you're doing it for a big practice, it's not usually the physician that's doing it and patients know that.

JONES: So, let’s unpack this a little bit more because there's I don't--and feel free to disagree--but I don't think that it has to be this way where, “Well, it’s don't come natural to me and I'm just not something that picks up my phone and takes a selfie or figures out all these different emojis, or all these filters. So, it doesn't come naturally to me. And I'm not younger and I’m not “cool,” so this isn't for me.” I don't think that it has to be that way. I think that the people that are killing it, that is it for them. They’re cool people. They’re people that you'd want to hang out. They’re really good at social media. It's nothing for them to just take a selfie, to bang out a thousand letters and use the right emoji, then just have it written in a way way that it's gonna do well. That is something natural, something that they can't be taught. But I do see other physicians, you know, even docs that are just a couple years out from retirement. It's like when we can get to do it in their own way, it does really well. We work with one doctor who is in independent practice and he's just a couple years out from retirement. He really doesn’t like social media, he just doesn’t like it. It's not something that he would do himself. Okay? Well, let's call him Dave for this. Dave, does a Facebook Live series, like you don’t have to do everything, but let’s do a Facebook Live where we talk about a couple topics. And he's young, he’s not “cool,” but Dave, if you’re listening, I think you're cool! His patients love him because he's a great doctor, he’s a great man, he's truly a kind person that really wants to serve his patients. And when he does these Facebook Lives, his patients come out and they say, “This is the doctor I was telling about!” And the women on my team, almost all of them have gone through fertility treatments, they all say if he was in our area, we would choose him as our doctor. It goes contrary to what is very common of, I would prefer a younger, female doctor, I would prefer someone who is--I don't know--more in line with social media. But if you can just participate, if you can engage, if you can show what your natural strengths are, there's a lot to be done. We’ve gotta spank them in order to be able to do it! We’ve got to ride them because they’ve got everything else going on with the practice and that’s their focus and this isn’t something that comes naturally. And even though they’re getting a ton of positive feedback, both from the business and from just patient feedback, it's still something that I feel like if we were on top of them about, it would just go all the way. And that is the case just with a certain generation and crop of doctors. So I would just be interested in your thoughts on, for those that aren't--they wouldn’t just naturally pick up their phone and start being on social, what could and should they be doing?

PERFETTO: So, as cool as I am, I have to be honest that this was not natural for me at the beginning either. Even now, I'll look back at my phone to try and find pictures from residency, or fellowship, or med school to try and post like old pictures, and I have none of myself. So it was not like I was selfie-ing-it-up before here. I actually was not still selfing-it-up at all. The thought of that, it made me uncomfortable and maybe kind of cringe to, like, put my face in front of the photo. So I had to do a major shift in sort of the way I thought, too. So, I mean I definitely jumped in with both feet. I will admit that I really, really like the creative side of it. So for me, this is a really great creative outlet. I think if you can find something about it that intrigues you and you like, then you kind of jump on that part first, and then you work backwards on the other stuff that has to be done. So, I really liked the fact that I could make my grid look pretty and I could write what I wanted to write the way I wanted to write it. So I had to adjust my comfort level with pictures because that's what Instagram is really all about. But if I got a good picture then I could draw people into what I wanted to really express, which was the post. So I think if you find what you excites you, then you can adjust the other stuff around it.


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JONES: You jumped in with both feet, you talked a bit in the beginning of the episode about the impetus for that, but I want to talk a little bit more about it. So, my timeline is probably that you were three years into your practice when you jumped in with both feet?


JONES: So you’re new to the market, you did not grow up in the market that you practice in right now. You didn't go to medical school there, didn't do any of your training there. So, do you think--if you’re being introspective--okay, so this is why I started, you mentioned in the beginning, I started because of marketing. Had you been super established, like, this is my home town, I’ve got relationships with all the OB/GYNs, and my practice is my own practice, not my group, my own practice is really established. Do you think that you’d still jump in with both feet?

PERFETTO: I don't know that I would! I don't know that I would have! I think somebody told me to do it. Somebody was like, you should be on Instagram. You should put everything that you're saying to your patients out there for everybody else. And in that moment, I think I had like a quiet month where I hadn't seen a lot of new patients, and I was like, you what? I'm gonna take that advice and I'm gonna do it! And I actually took that advice--like I've only going to give it like four weeks. We'll see how it works. I'll probably only have like 22 followers and then if it doesn't work, I'll just pull back from it. And within, like, four weeks, it just exploded. I put out one post that was about how fertility is not an industry and just explosion from patients, and in followers, and people wanting more information from me. And it really shifted the way I was thinking that oh, this is just something that I might do to something that this is actually, I would say, is actually part of my job at this point! Like I post almost like it's part of my job.

JONES: It is part of your job. I think that is a really great way of looking at it. You recognize that it is part of your job because the level that you've gotten to. And what I see very often is just that most people that have their practices established already. it's they don't have that impetus to jump in with both feet and it’s not part of their job. But, I can just see the relevance shifting away and not really even that's slowly either. There are doctors that were not even certified REIs five years ago that are now among the most influential in our field. And I think right now it’s still, for a lot of folks, there’s just still enough given the caseloads, and demand for treatment and services, and the supply of REIs and advanced providers that provide fertility treatment has blown up. But I am starting to see it more and more when we are starting to talk to practices where they've got weak social media presence or is outdated marketing or outdated communications. I'm seeing, okay now it's starting to slow down. Have you seen anything like it affecting your practice load? Or would you say it’s still a work in process?

PERFETTO: Oh, no, I definitely think that it has positively impacted the number of patients that I see. So I still see a fair number of referrals from OB/GYNs--those are really great referrals. But I see, like I said, a fair number of people who just found me on their own. People see their OB/GYN maybe once a year, maybe once a year. And if you're trying for a year and you see your OB/GYN, you've only been trying for six months, then you see your OB/GYN and now it's 18 months. They very well could be doing all of their own education on fertility and infertility in that year break where they’re not seeing an OB/GYN. So a lot of these younger women are referring themselves. They're not being referred by their doctor.

JONES: We've done a preliminary survey on some of this and I’m trying to get a few more partners involved so we can just get a bigger data pool and I'd like to work with a statistician--someone who is used to submitting abstracts at ASRM. But we’ve started digging into patients--like exactly what referral even means. And the preliminary data that we have is that only 25% of patients are given a strong recommendation for 1 REI. And another, I think, maybe a third or so are given a couple options. And then another quarter aren’t referred at all. And then we look, we look even deeper. We have data for all of our clients. For all of our clients, 60% would be really, really low if we’re looking at online reviews. Almost all of our clients have 70-75% of the new patients. This isn't someone that--this isn't Google Analytics saying it, this is the patient inside the office, actual new patient, not just a lead--70% or greater looking at online reviews. In our survey, again our sample size is still pretty small, it’s at 90% of people. Even when they were referred, they’re looking at online reviews and social media. And this is one thing that I constantly have to correct clinics on when we first start working with them. They are obsessed with single point attribution and single point attribution is dead wrong. This isn’t 1996 where they say here's the REI go see them, and that’s how the person came here. We have an entire cart of all of the different points that someone falls off the journey or makes a different decision--all of these are different decisions and they have different points of how they make those decisions. And the referring providers a very strong one, but it's still only one. And so we're obsessed with just diving deeper and deeper into this, but one thing that try to correct people on is forget single source attribution. There's not one reason somebody chooses your clinic. Some are stronger than others, but we want to identify all of the main main reasons why somebody chose your clinic. And so we are always asking yes or no questions. We don't have one single field for patients to say, “How did you hear about us?” And that is the point of single point attribution. But I also wanted to make the point that you are probably, I would imagine, that you're building relationships with OB/GYNs in your area from social media?

PERFETTO: Very much so, very much so. I mean actually, like, two days ago, one of those OB/GYNs was like, “Hey, let's get happy hour!” and I was like, “I've never even met you. We should get happy hour!” So, yes, I am definitely building stronger relationships that way. When I when I market out in the field, when I go and see OB/GYNs, the first thing I do is I tell them about my Instagram. I’m like, you should either follow me or if you're not following me, you should be able to provide this information to your patients because they may not be ready right now to try, but they might secretly be wanting to read a little bit more about it. And I think a lot of OBs give out that information. So it may not be end up with the patient in that very minute, but I do see a lot of patients probably from that.

JONES: So that example of somebody reaches out to you for happy hour--you didn’t send somebody to their office to give them bagels, you didn’t send somebody with pamphlets. This is a relationship that you made on social that different people can make using hashtags, by looking for the doctors in your area, following them on social media, commenting on what they’re doing, contributing to their conversations. It’s not, “Hey, do you want to send me patients?” It’s just contributing and building the relationship. And then when you are seeing them in person, you're also giving them something to stay in touch with and stay top of mind with. And giving them a reason to share your name with patients other than just, this is someone that you can seek for treatment right now, but--because it's a big decision. So they can refer that lead to someone, to that physician, but they can also say, “Here's some more for you to check out,” and then by the time it is time to make that referral, you're already the natural choice and/or they just made it earlier and it's the social media that nurtures them the rest of the way by the time that they actually make that decision. There are all kinds of ways where we can do this and one of the clients that we work with, they work with a higher physician liaison and they had just kind of lost OB/GYN referrals, bit by bit over the years another group had come in and done a better job with that and we don't really have any resources to send someone there to go do door-knocking. So I said, let's just try a content program. Let's try a content program where we are reaching out to other OB/GYNs. Still really early to tell, but those first three months of doing that the OB/GYN referrals were almost 40% higher than what they were. It's the same thing as bagels and pamphlets, just a lot more meaningful and you don't need to send someone to the office to do it.

PERFETTO: Exactly. I think I do think that there is value in sending somebody to sort of maintain relationships that I can't get to all the time. Like sure, I have a great group of OB/GYN friends, but I have a lot of colleagues out there that I just can't get to their office all the time. So there's definitely value to having somebody, kind of checking in and making sure that nothing slips through the cracks, but the social media is another way for people to stay in touch and--just a different version.

JONES: And even that person they've got access to the practice’s social. One thing we tell people all the time is that we can’t do all of your social. We can the ads, we can create content, we can do video, we can do community management--there's a lot we can do, but we got to the point where every single practice needs some in the office--what I call it. And so if your clinic liaison has thumbs, which they should, that should be part of their responsibilities--collecting content around the practice. They go do that drop off. They could take a picture or they could take a selfie with the team if they would let them. They could just take a picture out front. They’re like, “Hey, there’s this OB/GYN group that we have a relationship with, they’re great, they’re located over here,” and we can do that with every group. If somebody complains, “Hey, why do you blow them up and not us?!” Well, we’ve got to right now! As opposed to--there’s so many different ways to be able to augment the relationship from social media. And I don't have a large following, but I feel like I know almost everyone in the field because I use social media as more of a one-on-one and to nurture those relationships in the ways that you're talking about. And also to your point, one of the ways that I've noticed that our podcast has been growing in distribution is from reps--pharma reps--that are bringing it to the doctors and they're saying, “Hey, did you hear about this guy's podcast?” And it's content that allows one to do that. I’m going to talk about that a lot more, but you had mentioned something earlier in the show that I’d love to get your perspective on which is--I just I loved how proud you were of your practice group. Saying like, “Very respectfully, I think we're the best.”I think that there's so many doctors that would love to have a younger doc like you to be repping practice like that and to be going and be part of the group. And we should probably say that your with an independent group. Right?


JONES: Which I think is probably the largest independent grouping in your market now and--

PERFETTO: I think we might be really, besides academics, I think one of the only independent groups and it's really nice to be a bunch of doctors making decisions for our patients. And I would not have changed my decision to join this group in the least. Never would I have changed my decision.

JONES: Why is that important to you?

PERFETTO: Well, when I was looking for a practice, I really am all about my patient care and I wanted to make decisions for my patient. I want my patients to know that I am their doctor from their first visit to the first IUI to their miscarriage to their IVF cycle, their embryo transfer, and that I am going to be the doctor for them, making decisions for them basically the whole time. And although there are five of us and we work really well as a team, we’re sort of almost like individual practitioners for most of the time. So I sit down and I look at every ultrasound. I look at every lab test. I sit down my nurse. My nurse calls and makes sure that my patients understand what's going on. And that was really important to me. There wasn't, like, a group of doctors making a decision on my patient in the middle of the day. And a lot of big, big practices that’s how they work! And so when I sit down with the patient if they have a cycle, that did not go well, I can say, “This is what we did to try and fix this, or this is what we did during the process and try and improve it.” And I know that I did everything possible for that patient. So that was super important to me when I was looking for practice to join.

JONES: We talk a lot about, on the show, about recruiting younger doctors. And I was at PCRS this year, for example, every single doctor that I saw comes up to me and says, “Do you know any of these fellas? Can you introduce us? Are they looking to…?” Yeah, you and everybody else! By the time their second year hits, they’re already locked up! It's that competitive. And one of the trends that we're seeing is that there are less going to independent groups, there are more going to larger groups, most of which have equity partners. And so, you still see the--you are one of these exceptions that being independent is really important to you, that you’re super proud to be a part of this practice. Is there still space for that for the fellow class that is now, the folks that are coming out the next three years and beyond.

PERFETTO: I think we are one of the smaller subsets nowadays. I think that, obviously, more big practices of being owned by private equity and by venture capitalists. That is something that was not overly attractive to me. I, like I said, I personally like the fact that I make a lot of decisions in my practice. Personally like that.I was offered partnership in my practice. All of those were really important to me. I do think that the way that some of the newer doctors think about medicine is a little bit different. I wanted a partnership. I wanted to be also learning the business side of things. I wanted that in--I wanted that growth potential from when I finished. A lot of the other doctors maybe don't feel that desire, that need. Just the younger doctors are probably being offered more than I was offered when I started, but I also saw the potential in the practice. That maybe isn't there if you're joining a practice that is backed by a venture capitalist group. So that's really where my brain was at: I wanted to learn the business side, I love medicine, but I also think that's a really interesting part of of medicine and I think that it's constantly shifting. I think that right now we're going to be super hardcore venture capitalist-directed, but in a couple years, we may be like boutique medicine! And venture capitalists, patients are going to push away from that. You really don't know where medicine is going to be and I wanted to kind of get my feet wet in every aspect of it. And, to me, the finances were important, but we're all great. We're all doing well. No one is hurting in our field. And to me, having a lot more autonomy over my patients, over the practice, being able to sit down with my practice on a Thursday and say, “Hey, I want to add this protocol,” and the next day being able to start doing it was all really important to me.

JONES: I use the regional bank analogy a lot of where we're going to boutique or owned by private equity. Look at in just about any city, there's probably a small bank in the suburbs somewhere with maybe five locations, then they merge up with one of the other banks in the suburb, maybe they’re like the third biggest bank in the city. And after maybe one more of those they become the biggest bank in the city and they merge with the bank from two cities over--like the Dallas and the Houston one, or the Buffalo and the Cleveland one or Orlando and Tampa do--and they become a really big bank and then they get gobbled up by City or HSBC or whoever it may be. But then it starts all over again. And just like craft breweries, right? There is Anheuser-Busch, MillerCoors, then SAB bought MillerCoors, and then InBev bought Anheuser-Busch, and I think that they might be trying to merge those now, but every city, even the smallest of cities, have over a dozen craft breweries now, and I see that happening in our field as well. But what about groups, your side? It might be worth talking about? It’s not a single practitioner group, and those are the folks that would describe themselves as boutique. But you don’t have 20 docs and four labs in three different states. Are you all five doctors?

PERFETTO: There's five of us.

JONES: In one city in the metro area?

PERFETOO: Yeah, we have five doctors, four locations. So we are located--like I'm in the Medical Center, we have an office in Memorial City, our main office is in Clear Lake, and then we have another office in Beaumont. So in the last 5-8 years, we've had some really healthy growth. I mean, we've had pretty significant growth. From increasing our doctor number--I was the third or no, I was the fourth, but right before me is Dr. Crochet who's the third, and right after me is Dr. Kathiresan, who's the fifth. So we had some pretty healthy growth pretty quickly, as well as the expansion of the clinic locations. So yeah, I would not consider us boutique by any means. I think that was more like the future might be even more kind of boutique medicine. But I do think we have definitely more patient-centered care, just because we're a smaller group. And each of us has a prime location and so we sort of see the same staff all the time and we see the same patients. So from that perspective, we're kind of a medium-size group. And I mean, people ask to come and purchase us all the time! It’s not something that we haven't heard about. It's just not where we are right now.

JONES: You're a great size for their numbers--the market, the size of your practice--that's what they're looking for! Especially because in your market, there must be options that are off the table!

PERFETTO: That’s right! It makes us even better looking!

JONES: What do you think the future for that size of practice? I know one single doc practice. They run that office with seven people--that’s pretty darn impressive. That's a boutique. And then of course, we’ve had the largest practice groups on the show and I see how their economics work up. What do you think about practices your size? What do they need to do to remain independent and remain successful?

PERFETTO: So I would say we are certainly much larger than seven people. The bigger you get, you definitely have growing pains. So we've definitely experienced the growing pains whenever we’ve added a new location, but whenever we do add a new location, we basically go all in. So like patients aren't going to be only able to go there on a Tuesday. So, you know we put the full-on effort into any new location that we start. And I think that's important for patients--is that were not just like throwing ourselves all over the place. But I think that the positives of going to a practice with 4/5 doctors is that there's always somebody available. So the positive from my perspective is, I can take a vacation and not be stressed out of my mind that no one's watching my patients. Because I trust my partners wholeheartedly that they can do that. And if something were to go wrong and I was in the operating room, one of my partners could check on that patient. I wouldn't be stressed while I'm in the operating room about something else going on. There's definitely a benefit of having more than just one doctor. I was not looking to start my own practice when I started, and I was not interested in joining a practice with just one other person, because in addition to being a fertility doctor, I'm also a mom and I have other parts of me and so I really wanted to have a practice that I loved, but also let me be a mom and do things that are outside of just being a physician. So that's where I think it is a good middle ground for the physicians. So the patients feel good, get good quality of care with their one doctor, but if it doesn't work, we can always mix it up or--say somebody doesn't like me because sometimes patients don't click with me! There's you know, there's some patients that don't click with certain doctors. They can easily transfer to another doctor in my group as well, which is nice.

JONES: Well, Candice, we’ve talked a lot about how relatively newer doctors can build their practice, how to choose practices, what the future for them and different practice types is and how they can use social media and new forms of communication to do that. How would you want to conclude with our audience?

PERFETTO: I would say that if you are finishing fellowship or getting ready to finish fellowship you are even well-established, that if you have the opportunity to put yourself out there, take it. Find what makes you unique and happy in that space and then work on the other parts that make you a little bit more concerned and you will thrive. I really, truthfully believe that you will thrive, but you have to go in, both feet, jump in, take a dive, and it takes time. Like I'm a year and a half in, and I just hit 10K--I just hit 10,000 followers. So I mean it takes time to really build that relationship with other physicians and other followers and get that patient base to come in to see you, but it happens. You just have to foster it.

JONES: And you should follow Dr. Perfetto on Instagram. We will link up to that in the show notes. Dr. Candace O’Hern Perfetto, Houston, Texas, thank you very much for coming on Inside Reproductive Health.

PERFETTO: Thanks for having me!

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 to begin the first piece of the Fertility Marketing System, the Goal and Competitive Diagnostic. Thank you for listening to Inside Reproductive Health.