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IVIRMA is so large that they had 1,400 attendees at their international congress alone.
But what does it take to implement change, scale care, and keep the patient experience high inside an organization that large?
This week’s guest, Dr. Thomas Molinaro, Chief Medical Officer of IVIRMA North America, shares what’s working, what’s still being figured out, and what challenges fertility networks of every size should be preparing for.
Tune in to hear about:
The AI solution they’re using to save REI time (and how it’s going so far)
What they’ve learned from piloting patient journey platforms
Their APP-to-REI ratio and how they approach shared workflows
The evolving debate over who performs ultrasounds (REIs or sonographers?)
The marketing on behalf of REIs before the patient walks in that is critical to care
If you’re curious about the operational future of large fertility networks—or want a blueprint for scaling thoughtfully—don’t miss this episode with Dr. Molinaro.
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Thomas Molinaro (00:03)
At every level of the organization, we want a physician and a business leader to be working hand in hand, you know, to balance each other out. We obviously need organization, we need structure to be able to
run the company, but we also need to make sure that patients are brought along with us. And I think one of the unique aspects of our organization that sets us apart is that we really believe that our path to success is through our patient success.
Griffin Jones (00:41)
Many fertility networks don't even have 1,400 employees. IVIRMA is so big, they had 1,400 people just at their international congress. Dr. Thomas Molinaro is chief medical officer of their North American operations. How do you make change in an organization that large? How do you grow? Some of the things that Dr. Molinaro talked about, the AI that RMA is using to save physician time, the patient journey solutions they've piloted and why he isn't totally sold on
one just yet, the ratio that RMA uses advanced practice providers for and how they use them, the internal debate on to what extent REI should be performing ultrasound scans versus having them all done by ultrasonographers, the limit to how much you can scale an REI's time, and IVIRMA's point of view on mergers and acquisitions.
I hip you to an anesthetist staffing solution called Kaleidoscope Anesthesia Associates. They improve the patient experience, they support fertility clinics so that they don't have to worry about those staffing issues. Check them out at kaleidoscopeanesthesia.com. Finally, Tom shifted my point of view on some of the marketing that needs to be done on behalf of physicians ahead of time because of his thoughts on the openness of patients that is so critical for the REI to be able to do his or her job.
Enjoy this conversation with Dr. Tom Molinaro, Chief Medical Officer of IVIRMA North America.
Griffin Jones (02:29)
Dr. Molinaro, Tom, welcome to the Inside Reproductive Health podcast.
Thomas Molinaro (02:34)
Thanks for having me, Griffin.
Griffin Jones (02:36)
How has IVIRMA North America evolved the past couple years?
Thomas Molinaro (02:41)
That's a great question. I think we've grown pretty significantly over the past few years. Started a few clinics, had a few other clinics join us. I think that growth has been really great for the organization. It's also allowed us the opportunity to work on our infrastructure, building that out. We have a great leadership team led by our CEO, Wyn Mason.
And I think we're building a really strong culture here. And ultimately, it's an opportunity for us to continue to scale, to grow, and to help more patients achieve their dreams of having a family.
So this has been a really interesting time.
Griffin Jones (03:17)
Why has the growth been great?
Thomas Molinaro (03:19)
So this has been a really interesting time.
Griffin Jones (03:19)
Why has the growth been great?
Thomas Molinaro (03:21)
You know, I think it's an opportunity to learn so much from the people that we've come into contact with.
you know, the more experiences you have, the more new people you bring into the organization. Everybody has their own strengths that they offer. Everybody has their own perspectives. And ultimately, you know, we want to bring the best out in all of our, all of our clinics, all of our teammates. And so the more opportunities you have to cross pollinate, the more
you'll learn from each other. ultimately, I think it makes the organization stronger to have so many different viewpoints, so many different experiences.
Griffin Jones (03:56)
You hear about different competing axioms in business. One being that businesses grow too fast all the time and it puts a strain on the quality of delivery. Another one is if you're not growing, you're dying. Now that you've been at this for a couple years, how do you think about growth? How do you mitigate it so that it's the right growth?
Thomas Molinaro (03:59)
Hmm.
Yeah, I think that's great question. And certainly we don't want to grow just for growth sake. I think what we want to do is continue to expand in the right ways. We want to look for like-minded partners. We want to be able to bring the services that we offer to more patients. Clearly in this country, there's an access to care issue. And so more patients can benefit from infertility care than ever before.
There's more opportunities for insurance coverage and for other ways to access care. And so it's incumbent on us as providers to figure out how to meet those needs. And so as we've grown, we've looked for partners who share the same philosophy of putting patients first. And that's really what has helped us grow in the right way, is that we've always looked for ways in which we can deliver
the best care to patients and keeping them at the center of everything that we do.
Griffin Jones (05:12)
So you don't want to grow for growth sake, you being Tom Molinaro, but I wonder if a more accurate characterization is that you're going to grow as a company, but you have constraints on how you can grow, meaning that you have to maintain a quality of care or either maintain or improve the standard. not picking on RMA, but you're one of many networks that is owned by companies that are seeking to
Thomas Molinaro (05:17)
Yeah.
Griffin Jones (05:40)
return and investments, not a nonprofit. So these organizations have to grow. You're a physician, you need to be the standard bearer of not letting quality slip. How do you do that? How do you balance that?
Thomas Molinaro (05:55)
Yeah, that's great question. mean, I think, you know, our organization has really grown through, you know, we've been developing a dyad infrastructure. And I think Lynn spoke about this with you when she was on the show. But the idea is that at every level of the organization, we want a physician and a business leader to be working hand in hand, you know, to balance each other out. We obviously need organization, we need structure to be able to
run the company, but we also need to make sure that patients are brought along with us. And I think one of the unique aspects of our organization that sets us apart is that we really believe that our path to success is through our patient success. If our patients can be successful, we'll be successful, right? And so ultimately we're willing to do anything and everything to help our patients achieve their goals. And really, how do you measure patient success?
part of this. It's not just about how often do they get a positive pregnancy test, which is a big piece of it. That's something that we focus on, but it's also time to pregnancy. It's dollars to baby. It's patient experience along the way. And these are all of the essential components of how we run the business with those in mind first, patient safety, patient success, everything else follows from there.
Griffin Jones (07:14)
We'll link to the episode that we did with Lynn Mason, who you're referring to a few months back, and she talked about dyad leadership from her side of the dyad, the business side, and she gave some examples. What's a specific example that you can think of how you and Lynn approach a decision together?
Thomas Molinaro (07:19)
Hmm.
You know, I think we're at every opportunity, we're trying to figure out what do we need to make sure that patients have the best outcomes. So if we have a clinic that's growing and we had a clinic that saw a tremendous increase in volume last year, we had to make the right organizational decisions around staffing and support. What kind of embryology staffing did we need to be able to go from a batch center to a continuous center? And at the end of the day, how many nurses did we need? How many clinical staff did we need?
And so this is where I think the organization really excels because we have these discussions around what's best for patients and then ultimately try to understand how do we scale the organization so that it's cost effective, right? At the end of the day, we wanna make sure that patients are having the best opportunity to be successful.
Griffin Jones (08:17)
So in the case of the center that grew rapidly, is it about replicating those practices so that you have other centers that can also fulfill that type of volume? Or is it about now you have perhaps staffing needs, resource needs at a place like that that you didn't before and now you're trying to accommodate it?
Thomas Molinaro (08:37)
So it's a complicated question for sure. We do have staffing models that help sort of dictate what we think is normal for different sized clinics. At the end of the day though, every clinic is a little bit different. The geography might be different, the patients might be different. And so we have to understand how to customize that to the clinic in question. The other opportunity that we have is as we're growing regionally, the opportunity to share resources.
Right? So when you have two clinics that are close to each other, they actually can share staff. And so if you need to borrow an embryologist and the embryologist is two hours away, that's an opportunity where you can sort of help bridge some of the growing pains to make sure that patients get the care that they need. The lab, the staff are all taken care of. And at the end of the day, it will continue to develop best practices for the organization.
Griffin Jones (09:31)
How do you approach the speed at which change is implemented?
Thomas Molinaro (09:35)
Yeah, that's a great question. And I think part of it is in planning, right? We really are trying to anticipate. We're not looking at next week. We're barely looking at next month. We're looking at three, six, 12, 18 months down the road, trying to predict where we're going to be. Because if you wait until the volume is here, it's too late. We really need to be thinking proactively about how the clinics are growing. What are we seeing as the evolution of our patient needs?
and how can we prepare ahead of time so that we're not caught behind the apple.
Griffin Jones (10:06)
My only semi educated opinion of thinking about the market for the last few years and then where I think it will go in the next 10 or 20 is that REIs aren't gonna be doing 200 cycles a year on average or 150 cycles a year on average. They will be doing much, much more than that and they might be case managers of teams of
advanced practice providers, maybe of OBGYNs, having a lot more AI support, having a lot more automation. Do you think that that's the case? Do you think we're headed for, not next year, but in the next decade or so, a field where REIs are doing an average of a thousand, two thousand cycles a doc?
Thomas Molinaro (10:48)
Yeah, I mean, that's a lot of cycles and I certainly can't see the future. What I can say is that there is an opportunity to leverage technology, to leverage APPs, to really help our providers take care of more patients and operate at the top of their license. That's really what makes an efficient provider is when your providers are doing the things that only they can do, that allows you to just take care of many more patients. so part of that is
surrounding physicians and APPs with the right support staff. Part of that is physicians and APPs partnering together and trying to understand what are the patient needs that require the physician and what can be taken care of with APPs. And certainly we see it changing the model of care across our field. I personally think that our patients who have APP providers as part of the team benefit from having more eyes
looking at the chart, more hands to touch them in the clinics and making sure that they're having the best outcomes. And I think that most of our patients who have teams that involve both physicians and APPs have a great experience and really good outcomes.
Griffin Jones (11:55)
How has the use of APPs at RMA evolved in the last five years or so?
Thomas Molinaro (12:01)
Yeah, we have been big proponents of APPs in our clinics. I think that they have transformed in many ways how we are able to take care of our patients. We have different APP types. have procedural APPs that focus more on ultrasounds, saline sonography, different sort of in-office procedures. And then we have the majority of our APPs are paired with a provider, paired with a physician, really.
So I work with an APP. We see patients together. We talk every single day. And basically, she helps to direct me in the right ways. She helps to make sure that there's a second pair of eyes looking at everything. And that ultimately, our patients are hearing from one of us pretty frequently, whether it's me or her, kind of updating them on their progress, answering their questions. It really allows us to cover more ground.
And ultimately for me as a busy physician, it helps me to prioritize which patients are most in need of my attention on any given day. So I think that it's been really an extension of the physician to have that EPP. And that's what's allowed us to scale, I think pretty significantly as teams. But again, your team is stronger than any one individual player.
And so the fact that the APPs are really tied to a physician in such a tight way, think, has been a game changer for us.
Griffin Jones (13:21)
Is it a one to one ratio? there's one REI for one APP?
Thomas Molinaro (13:27)
For now, that's what our model looks like, for sure.
Griffin Jones (13:31)
Does she see patients at the new patient visit and then you see patients at the follow-up or vice versa?
Thomas Molinaro (13:36)
Yeah.
We do it all different ways. sometimes we see patients together, which is great because I love having her with me and she, her name's Rennie. So Rennie does a great job with me, kind of seeing patients in the clinic. Sometimes she'll do the initial visit and I'll do the follow-up, which can be really helpful for a patient who hasn't had a lot of evaluation ahead of time. You know, I can talk to them once all their test results are back.
right? And I can sort of come together with them and formulate a plan. but Reni did the introduction. She did the, the educational aspect. She's really good at making sure that patients have a good understanding of their situation. What are the tests? Why are we doing them? And what are the potential treatment options so that I can come in afterwards with the actual test results and formulate a plan. and we get lots of positive feedback from patients that they, you know, they recognize the value of the team.
Griffin Jones (14:25)
What do you like about doing it different ways? Sometimes doing the new patient visits, sometimes doing the follow up. Why not have it be all one or the other?
Thomas Molinaro (14:33)
I mean, I think it's just, it's a different way of doing things. Sometimes variety is interesting. You know, doing a new patient infertility consultation is something that I've done many times. It's a little more interesting to do, you know, a follow-up where you have test results and you can really speak to more specific aspects of care. Sometimes the really complicated patients that come around and having...
an opportunity to spend more time with the complicated cases really is rewarding as a physician.
Griffin Jones (15:01)
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Thomas Molinaro (16:40)
Yeah, I mean, I think.
A lot of what we've learned has been around communication. I think it's really important to communicate. And if you think you're communicating enough, you should probably communicate more. I always feel like there's more and more opportunities where we can get the right messages out to providers, to staff, with respect to the direction that the organization is taking, how we're focused on patient care.
getting everybody on the same page with respect to what are the priorities of the organization. For us, it's about helping patients achieve their goals. And so we always want to put patients at the center. We want patients to be the driving force behind our organization. And that means that our research is focused on how do we improve the success rates? Our patient experience team is focused on how do we measure and improve the patient experience through our clinics?
Communication for patients is just as important, right? mean, patient portal, all of the things that patients want access to, we're trying to make sure that they can access it within the app on their phone because communication is so important. So I think you can't underestimate how important communication is.
Griffin Jones (17:49)
Tell us about the investments either that you've made or that you're considering for the communication for patient side, because I think it's still one of the biggest pain points for clinics. I had Eloise Drain, the owner of a surrogacy agency called Family Inceptions on, and she was very blunt from her perspective. She thought that patient experience is getting worse, at least in the regard for patient communication across the board.
I still see the same negative reviews that I saw 10 years ago. And I know how difficult it is because you have so much going on in the clinic. Nurses have to do so much. You can automate certain things, but there's an exception to almost everything. And it becomes really hard to have an automated solution for, so you're back to the man hours and that burden. And it's extraordinarily difficult.
Yet we know that one of the biggest pain points for patients is just not knowing what's going on and feeling like they're gonna, or having an expectation that they're gonna get an answer by a certain date and time and then a couple of days goes by and they still don't have that answer. There are so many of these tech solutions. I need to do a better job of mapping them out like these patient triage and patient concierge, different types of companies, because I don't totally know all of the ways that each of them overlap, what they do differently.
But people are trying to solve this problem. What are you vetting or have you vetted? What are you looking at?
Thomas Molinaro (19:19)
Yeah, I mean, it's really important to understand that there's no simple answer to that question. I think that's one thing that we've learned is that there's lots of different ways in which patients communicate and lots of different expectations. Part of it is incumbent on the physician or the provider to set the right expectations for patients upfront. I think that's a huge part of this is
setting the expectation of how you're going to communicate with us. What's the turnaround time on some of these messages? And certainly that's something that our teams have tried to do. We have a patient portal app. our EMR is called Artemis. It's a proprietary EMR that EBRMA has built over time. It has a patient portal app, you know, and we're trying to put as much information into the patient portal app as possible.
Some of it self-serve, right? I mean, one of the questions that we get all the time is how many embryos do I have left and what's the sex of the embryos I have and, you know, et cetera. So the more that we can service that to patients in the app themselves, they can get those results, test results, embryo reports, all of those things right there. We have, you know, a chat function within the patient portal that nurses are answering. And again, trying to set the right expectations for what's an appropriate turnaround time for a message is important.
It's not an instant message. It does take time for nurses to get there. So on the other side of it, trying to understand how can we speed up that process with templates, with chat GPT instances. So we have a beta version of the chat GPT instance that will help the nurses write their answers back faster. And I think that that's just one way to try to bring efficiency.
to drive efficiency in terms of responding to patient needs and patient expectations. We're obviously interested to see what other technology is out there. We've embarked on a couple of pilot projects with some of those patient services that you mentioned. We haven't decided sort of how that's going to integrate with our system in the long run. We're still kind of feeling our way through that process. We're getting some initial positive feedback.
from patients, but at the end of the day, I think a lot of patients want access to their providers. And so how can we create the right patient touch points, sort of studying that patient journey and understanding that there's certain times in the journey when patients really benefit more from hearing from their provider, whether it's a physician or an APP, you can really maximize the impact by checking in at certain times, right? You I want to make sure that I'm checking in with my patients at some point during your IVF stimulation.
I don't want to do it too early, maybe in the middle of the cycle, kind of project where you are, what I thought you were going to get, when retrieval might fall. That one phone call has a huge impact on that patient's outcome if I can set the right expectations for the rest of the cycle. So that's just one example. I think it's hard because it is labor intensive. So the other aspect here is how can we automate the other parts of care that don't require my voice on a phone, right? And sort of surrounding...
surrounding our providers with the right support staff and the right tools to make these interactions more viable.
Griffin Jones (22:22)
That's my axiom for automation. Everything that should be automated must be automated. Everything that should not be automated must not be automated. Are those tech solutions that you're piloting or communications triage, concierge solutions, none of
Thomas Molinaro (22:41)
I think it's too early to tell with some of them. It's really still early days in terms of trying to figure out how all the pieces fit together. It feels a little bit like a jigsaw puzzle that you're trying to put together, but you don't know what the picture is. So we're still trying to figure out which patients benefit most from different types of care. And sort of the understanding has always been that there's one size fits all.
And I don't think that that's the case today. I think you definitely have patients who are looking for a different type of experience. so are patients looking for more information upfront? Are they looking for more handholding? Are they looking for more statistics? How do you create different journeys for patients to go on to get to the same place, right? Most of them want the same outcome, but it's a question of along the way, what kinds of tools and you know,
what kind of information do they need? And I've had patients who don't want to know anything. They just say, I don't want to know how the sausage is made, just get me to the end. And you have other patients who want to know why did you pick this particular dose for me? What are the characteristics that made you think of this? And so kind of somewhere in between is where we all kind of live. part of the way to solve that is actually asking patients, right? So spending more time at that initial visit is something that I think has become
really, really important to me as a provider to sort of see what is it that this patient needs? And I will ask, I mean, I've gotten to the point now where I'm not trying to read the tea leaves. I just say, hey, what are your biggest concerns? I want to make sure that we address that as we're going through the process. And I want to make sure that we're creating the experience that is going to help you achieve your goals because most patients are going to achieve success as long as they don't drop out of care, right? I mean, I think we're in a really good point of fertility care where, you know, the
vast majority of patients will be successful if they just keep at it.
Griffin Jones (24:28)
Would you describe that as the biggest challenge, that being finding solutions that are customizable to the varying needs of patients, or is integration a bigger challenge?
Thomas Molinaro (24:40)
No, think patient care is always the biggest challenge that we face, right? And trying to understand how do you create that experience for patients that makes them continue in their journey and ultimately that leads to a high level of patient engagement. And I think patient engagement is really the right word for what we're looking for. We want patients to feel empowered. We want them to understand where they are in the journey. We want them to feel free to ask those questions.
But ultimately to understand that we're on the same path together, we want the same outcome, right? As their providers, we want them to be successful. It's not fun to call patients with negative pregnancy tests, right? And so how do we partner with them? How do we make sure that they're engaged in that process? And ultimately that's what leads to great outcomes. That's what leads to patients who are really satisfied with their care is when both the physician and the patient are engaged in formulating that plan.
Griffin Jones (25:34)
Integration is tough though. Every one of these tech companies that I talk to when they talk about implementing with these networks, they say, we'll have eight different people, somebody from nursing, somebody from the lab, somebody from a couple of people from ops, maybe somebody from the C-suite, a couple of docs, and maybe from a couple of different practices from across the country. And they're all looking at how to integrate the solution differently.
Thomas Molinaro (25:39)
Yeah.
Griffin Jones (26:01)
How do you approach that with this dyad leadership? Are people coming individually and then it's coming up from like your team or Lynn's team and then it gets out of committee like in the House of Representatives and you bring it to the floor only after it's passed committee? How do you approach integration?
Thomas Molinaro (26:14)
Yeah.
You know, I'll be honest, you know, it's not that Lynn has a team and I have a team. We're all one team together. you know, and that's the way that we really focus, you know, at every, in every meeting there's both clinical representation and operational or just organization. you know, that's, that's present. we have a great chief operating officer, Edith Gonzalez, who really, understands that, patient care drives all of this. And so, you know, we can have conversations around,
patient-centered experience and how do we drive those outcomes? With respect to integrating any new solution, it's a series of trial and error, right? I you have to really try to understand and be willing to fail, right? Be willing to make mistakes and then reiterate and try again. And that's one thing that I think we're good at is really getting in there, taking our repetitions to try to understand what works and what doesn't.
Ultimately, we also think that there's an opportunity to try to standardize certain aspects of care, which helps to integrate, right? If every physician is doing things differently, then it makes it hard to integrate new solutions. But if we can all come to agreements and we try as physicians to say, okay, here's how we want to practice, here are the things that work for us, then ultimately, I think that allows you to integrate better. It allows you to set the EMR up the right way and all of those other...
aspects that streamline care.
Griffin Jones (27:34)
getting doctors on a page like that where they are so integrated is not easy. One of my favorite little bits from all of the podcasts I've done was a doctor named Kishits Murdiya, who's the CEO of Indira IVF, which is one of the largest networks in India. And he says, I hired 250 docs and it's not like they have REI fellowship there. So hiring 250 doctors might be more tenable. He's like, got 250 doctors.
Thomas Molinaro (27:38)
Yeah.
Griffin Jones (28:03)
I made sure all of them are younger than me and I told them, here's the protocols and we make decisions as a group together of how the protocols adapt over time. But this is the menu of protocols that we follow. We don't have somebody over here doing these couple of protocols and somebody over here doing a completely different set of protocols. Is that the future in the United States?
Thomas Molinaro (28:05)
Hehehe.
I don't think so. I mean, think there's lots of different ways to practice and some of the protocols matter and some don't. And we certainly don't tell physicians what protocol to use or how to take care of patients. I think what we've, yeah, it's a question. Because everybody has a different way of practicing and ultimately if you can achieve the same results, that's all that matters, right? And so that's where it really comes in is we want to be a data-driven organization.
Griffin Jones (28:40)
Non rhetorical question though, why not?
Thomas Molinaro (28:55)
Physicians practice evidence-based medicine every day. We should be looking at the literature. We should be evaluating treatments and trying to understand what works best. And ultimately, we should carry that over into our practice every single day with what we're doing. So as a data-driven organization, our EMR allows us to ask questions and try to understand what works best and what doesn't.
and ultimately try to come to some agreement around different treatment protocols. So we have a medical affairs group made up of different physicians, nurses, APPs that are looking at the literature. They're looking at our data, trying to understand what are the best practices. And we want to create opportunities for our clinics to take advantage of that knowledge. We don't force it down your throat. We sort of say, hey, look, this is what's working. This is what shows the best outcomes. And, you know, our physicians want the best for their patients. At the end of the day, why wouldn't you adopt
certain treatments or certain protocols if they lead to really great outcomes for your patients. And again, it's not just patient pregnancy rates, it's their experience along the way, their time to pregnancy, all of those other things that we're looking
Griffin Jones (29:57)
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can be automated or should be automated so that doctors can do those things where they need to provide more individualized patient care. I think... I don't know if this is a consensus yet, but it seems like the really bad news should be delivered by the doctor. And there are other times where the doctor probably needs to make themselves available. And then there are other things. It's like, why is the doctor doing that? So what are those things that
should not be being done by an REI or any physician.
Thomas Molinaro (32:18)
Yeah, I mean, I think, you know, it's obviously important for physicians to be available when patients have bad outcomes. They have lots of questions. It's a really pivotal time in their care. And it's an opportunity to not just answer those questions, but hopefully provide encouragement for patients to continue in their fertility journey. I think, you know, there's opportunities to increase
throughput if physicians don't have to make as many of the less important calls around, know, estrogen levels and medication dosing, those kinds of things, obviously. And nurses have done that traditionally for many years and moving more and more of that into electronic portals, I think has been helpful. Although patients do like to hear from their nurse, they like to know that they're doing well or that things are as expected. You know, I think, you know, ultimately,
just trying to understand what's the best use of physician time is a difficult question. And I think it varies from physician to physician in terms of what are the parts of their practice that they enjoy, right? I I would love to call a patient with a positive pregnancy test. I don't think I've called a patient with a positive pregnancy test in a few years because the nurses jump on those phone calls first. And by the time I get to look and see what's happening,
it's the middle of the day and the only phone calls left are the negative pregnancy tests. So, you know, I think we all need to figure out what's the best use of our time. And it may not be the same for every position, but certainly automating tasks like, you know, progress note writing, right? So, I mean, how long does it take to write a progress note after you have a conversation with a patient for 45 minutes? You know, we're, we're, are looking at, you know, AI scribes for that type of work, reviewing records, right? You get,
100 pages of old records from somebody who's coming for a second opinion. There's automated solutions that allow you to summarize those records and, you know, means less work for the physician to go through each and every one of those pages and try to summarize and extract the important, you the important points. So I think there's great opportunities for, you know, technology to improve the efficiency of physicians and
and other practitioners, APPs as well, so that we can spend more time doing the hand holding, making the important phone calls, spending time with patients, and that's what keeps them engaged in care.
Griffin Jones (34:28)
Progress Notes is a major time suck as someone married to a physician knows. It doesn't just end at the office. And reviewing the records, having the AI to summarize that. What about ultrasounds? Should doctors be doing ultrasounds?
Thomas Molinaro (34:30)
Yep.
That's a great question. And in our network, we do have some clinics where we use sonographers and we have a lot of clinics that use providers. And it is double-edged sword. I mean, think it is a large use of resources to use providers for scans, but I think it improves patient experience. So I'm pretty torn about it, Griffin. I won't lie to you because I enjoy scanning. I scanned yesterday. I got to see a lot of my patients in care.
provided them immediate feedback, got to do some pregnancy ultrasounds, which is always fun. And so for me as a provider, it's rewarding to have that patient touch point. I think it's rewarding for patients to get that immediate feedback and to also be able to ask questions. So what we've tried to do in our clinics where we use providers is have more providers rotating through. So no provider is doing scans more than
twice a week at most. I think that really helps to sort of balance the burden because it does take three hours of my morning when I scan and that's three hours that I could be using for other things. But to me, it's important to have those touch points and to be able to interact with my patients and offer them my own sort of perspective on how their cycle is going, give them a little bit of hope, a little bit of optimism, hopefully, or if it's a cycle that's not going well, it's an opportunity for me.
to sort of have a little discussion with them face to face. You know, and always it's, okay, we'll follow up later this afternoon with a phone call after we see your, you know, your blood work, but at least we've set the stage for some of those difficult conversations that we're gonna have later in the day. So I certainly think it's a benefit to patients.
Griffin Jones (36:16)
You're torn though. It sounds like you haven't totally come to a conclusive decision. And on one hand, you feel like it's sometimes you really like doing the scans. It's a meaningful touch point with the patients. To me, it's like maybe there's a case for the efficiency of using stenographers. And I wonder if there's a way to systematize getting that benefit that the patient feels from
when the doctor's doing their scan in terms of like that really warm and personalized care, if there's a way to extend it and systematize it to stenographers. And I think of an example, one of my earliest clients back when we were doing marketing for clinics was Fertility Institute of Hawaii. there was a phlebotomist there that was like responsible for just an insane number of their positive reviews. They really just loved, I remember her name, her name was Zoe.
And so shout out to Fertility Institute of Hawaii and Zoe because people loved this phlebotomist. And I'm thinking there's no reason for a nurse or anybody above a nurse to be having to stick people when you've got phlebotomists like that because the patient experience and personalized care has somehow been transferred to her. Do you see any way of being able to do that, to systematize that for stenographers to where
Thomas Molinaro (37:05)
Hehehe.
Griffin Jones (37:34)
So docs aren't doing it just because they need to feel this individualized care, but somebody else can provide that to the patient. Is there a way of being able to scale that?
Thomas Molinaro (37:44)
Yeah, I mean, it's good question. mean, you know, you're always going to have outliers. sounds like the Phlebotomist is an outlier in all the right ways. The question is, can you train other people to be that way? And I don't know that you can. I think some people just have it in them. You know, they're outgoing, empathetic people who really connect with patients. You know, it's not to say that it can't be done, but certainly it requires, I think, extra training in
in terms of helping the sonographers understand more of what's happening. But I don't think there are ever going to be a substitute for a provider. I think an APP or a physician in particular really understand the treatment on a different level. And patients are really looking for that validation. That's one of the biggest things that I see is just the fact that they hear it from a provider makes a big, difference.
Oftentimes I'm saying the exact same thing that the nurses told them, but because it's coming from me in this certain situation, it resonates more with the patient.
Griffin Jones (38:42)
Are there any things that really just chap your ass that doctors are doing though? Any example in family medicine, I go see my family medicine doc. I've been on a very small dosage of a controlled substance forever that is a very minor part of my life. She's gotta spend 15 minutes going through all these New York state rules and then I don't even have to sign anything. So it's not even like for informed consent. It's like.
Thomas Molinaro (38:52)
Hmm. Hmm.
Griffin Jones (39:05)
One, I wasn't paying attention to you. We could have had some maybe video modules, some engaged MD type thing where I have to sign off, at least like get informed consent. I could have done this in a video module that has, that doesn't take up your time. And then she's asking me like, do you want this vaccine? Do you want this vaccine? And I'm like, I don't know. Like, am I at risk for it? Like you tell me, like I'm about to be approaching middle age. I'd kind of like it if my family medicine doc was able to be.
Thomas Molinaro (39:07)
Yes. ⁓
Griffin Jones (39:32)
a little bit more proactive of here's what's gonna come up and I think part of the reason why they can't do that is that they're doing all of this crap. Is there any examples like those that you see in REIs that like, this is a waste of our time?
Thomas Molinaro (39:44)
No, I I think we're fortunate in REI that we're in such a sub-specialty of medicine and we have a great opportunity to help so many patients. I don't think that there's anything that we do that necessarily is a waste of time per se. I do think that it's great when physicians have more ability to ask patients the right questions, right? To really...
give them the time and the opportunity to communicate their concerns, their fears. I I start every new patient consult with some very open-ended questions. What brought you in today? How did you get here? And trying to understand the journey that they've been on, because it's been, for most of these patients, months, if not years, of trying at home and talking to their OB-GYN and talking to their sister or their friends. And so for me to catch up on that journey, I need them.
to really open up. I need them to really speak all the thoughts that are in their head. Number one, it helps me understand them better, right? Number two is that they're not actually gonna hear anything that I have to say until they've emptied their brain, right? Until all of those thoughts that are in their head are out on the desk in front of us. And then we can say, okay, let's put all these pieces together into a plan. And so I think that if physicians took the extra time to ask those questions, to really hear what patients are saying,
They would be much more effective at formulating the right plans and speaking to their concerns. And I actually try to repeat back to the patient what I heard to double check myself. So at the end of all of that, before I launch into any of my explanation about the testing or the treatments or anything else, I just try to repeat back. you're 34, you've been trying for a year, you went to your OB, they did these tests. Right now, it doesn't seem like there's any issues. Your biggest concern is around insurance coverage. Am I missing anything?
And yeah, I'm missing stuff. They correct me all the time that I forgot, you know, there was some important key aspect that didn't register with me that they're going to correct me on right there and they say, no, but you I also have this family history that I'm worried about. Okay. Once we get all on the same page, now we can work together. I can partner with that patient. We can engage in a conversation about testing, about treatment. We can formulate a plan. And that's really, really important to patients is that they have a plan, that they know where they're going.
right, that they understand the journey that they're about to take. And that ultimately helps us to engage in the right kind of care.
Griffin Jones (42:08)
Did you guys, meaning you all as an IVIRMA Global, just have a mini conference or not so many? My notes say 1,400 experts. You had a meeting of 1,400 people? That's like PCRS, MRSI, like CFAS. It's bigger than those meetings put together. It would probably be like the fifth. It's probably somewhere in the top 10 of largest meetings.
Thomas Molinaro (42:18)
We did. Yeah, so...
Griffin Jones (42:34)
in the world for fertility if I had to guess. What was this all about?
Thomas Molinaro (42:38)
Yeah, so every other year, EBRMA puts on the ED Congress, which is a three day meeting in a city in Spain. So this year was in Barcelona two weeks ago. We invite REIs from all over the world to attend. We invite a lot of the top minds in the field to come and give research presentations around different aspects of care. We had some male infertility, we had some...
AI, had some ovarian rejuvenation, some in vitro gametogenesis talks. It was a really well attended conference in a beautiful city and just really allows many of the experts in the field, many of whom are IVIRMA physicians, to speak on their area of expertise.
It was a really great conference and I think everybody had some really positive feedback to give every other year in Spain. ⁓
Griffin Jones (43:29)
What were the biggest takeaways? What did you leave with saying,
we've got to implement this the next year?
Thomas Molinaro (43:34)
Yeah. I mean, think the biggest takeaways were around, certainly around AI. AI is here. There's ways to use it in the clinic that can make you more efficient. There's certainly opportunities in the laboratory that are going to come around and make us more successful. It's really exciting to see some of the work being done on in vitro gametogenesis, right? And so understanding the ability to
to grow sperm or eggs in a dish. I think that it's something that's probably gonna happen within our lifetime, that these researchers are making big strides and certainly that will change the face of how we take care of patients. It's interesting that there's still a lot of talk around endometriosis and gnatomyosis after all these years and looking at new and novel ways to treat it, both surgically and with medicine.
And I think we're all looking forward to the automization of the IVF laboratory and seeing what's coming down the pike in terms of robotics and sort of really making the laboratory more efficient.
Griffin Jones (44:34)
Do think that's pretty close?
Thomas Molinaro (44:36)
I mean, I think it's certainly on its way with some of the organizations that are putting this forward. And I think time will tell how easy it is to implement in the clinics. And ultimately, we're excited to be a part of it, I think in general. At IVIRMA, we've always wanted to push the envelope. We think that there's tremendous opportunities within the field to improve.
our success rates to improve our ability to care for more patients. And so we've always had a dedicated R &D division that looks at the latest technologies, partners with different startups and tries to really understand how we can improve the delivery of care. until we get 100 % of the patients pregnant 100 % of the time, we can always do better, right? And so I think that's what drives us as an organization is to always want to be better.
And the way that we practice IVF today is different from how we practiced it five years ago. And I know that it's going to be different five years from now. We'll look back and say, can you believe we were doing it that way for all those years? And the answer is, yeah. Because until you do the research, until you push the envelope, until you're willing to step outside of your comfort zone, you can't change. And change is uncomfortable, but change is absolutely necessary if we want to continue to deliver the best outcomes for our patients.
Griffin Jones (45:57)
Part of the reason why the meeting is so big is because the organization is so big and that's partly because of acquiring merging with other clinics, clinic networks, Boston IVF, TRIO. What have you learned from those acquisitions? What are future acquisitions that might happen in the RMA ecosystem?
Thomas Molinaro (46:03)
you
Thank
Yeah, well, I don't have a crystal ball to know what's coming down the pike. Certainly we are interested in working with the best clinicians that are out there, the best clinics that are looking to partner with us. I think every step of the way we try to learn from the organizations that join us and really understanding what they do well. And certainly from Colorado Conceptions in Denver, we learned a lot about
efficiency in the laboratory. From Boston IVF, we're learning a lot about their organization, their efficiency as well. How do they approach patient acquisition? There's a lot of opportunities for us to learn more from the other clinics that join us. And certainly we want to form a new way forward, sort of learning from all of the clinics that join us to understand
what will drive the best outcomes. And we are, you we have always been as an organization unafraid of change. You we're willing to change tomorrow if we think it'll get a better outcome. And so I think that's really refreshing to get to meet other REIs, other clinic leadership, understand what they're doing and try to figure out what we can steal in order to get better outcomes for our patients.
And honestly, having a data driven approach allows us to do that. It allows us to sort of do A and B testing and see which one leads to better results. And, you know, I think that's what keeps me going to sort of meet new people and understand better ways of taking care of patients.
Griffin Jones (47:43)
Any breakthroughs that you plan to unveil this year? Research or otherwise?
Thomas Molinaro (47:47)
You'll just have to wait to see.
No, think, you know, we have, I think 40 or 50 abstracts that we submitted to ASRM, you know, some pretty good projects. You know, we'll see what gets accepted and, you know, hopefully we'll have a good representation of the meeting in October.
Griffin Jones (48:03)
If you could give an assignment to all the people listening that there's someone in the audience that has a magic wand, it can make it happen. What challenge do you still feel like really needs to be solved in this space? What do you want to have a market improvement in the next five years or so?
Thomas Molinaro (48:17)
Thank
Yeah. I mean, I think we're still scratching the surface of embryo diagnostics. We still don't know what makes a good embryo, right? Even when you have a genetically normal embryo in a young patient, the chance it turns into a baby is still less than 70 % in most cases. So we're missing a lot when it comes to embryo diagnostics and whether it's something that has to do with genetics or whether it's metabolism, I think there's still a lot of work to be done.
understanding what makes an embryo that's capable of implanting and turning into a baby. So we're certainly working on it in our research organization, but I think there's a lot of opportunity for others to help us figure out what makes a good embryo.
Griffin Jones (49:00)
And there's a lot more that could be discussed in this podcast that we'll have to wait for another episode when we have you back. Dr. Tom Molinaro, thank you very much for coming on the Inside Reproductive Health Podcast.
Thomas Molinaro (49:12)
Thanks so much, Griffin.
Dr. Thomas Molinaro
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