Journal Club Global: The future of REI Fellowship training: debating opportunities and threats

Good afternoon, everyone. My name is Micah Hill. I am the media editor for Fertility and Sterility.

We are delighted to be here once again partnering with PCRS to bring you a Fertility and Sterility Journal Club Global. This year we've taken the non-controversial topic of the future of REI fellowship training in the United States. A lot of passionate opinions and thoughts from great leaders on this topic.

So why is Fertility and Sterility a scientific medical journal talking about REI fellowship? Clearly, this is at the crux of the future of our field and FNS has really taken a lead and being a place for the discussion of this topic as led by our editorial editors. For example, editorial editor Marcel Cedars in a paper just in press this week, who will be the teachers of the future? Who will move our field forward? What type of research will be trained and who's capable of doing it? To save REI, we need to learn more, not less. We need to challenge more, question more.

That can't be done without foundational knowledge. Eric Widra, editorial editor in the last year, let us not fear change, but embrace the needs of our patients and colleagues. We stand to thrive from going back to the future with two-year fellowships.

Editorial editor Nanette Santora, two articles on it, suggesting our field is getting so complex, we need to add G to REI for genetics. She says, I'm calling all REIs to step up and take control. We need to preserve the breadth and practice and knowledge that makes this the best and most satisfying career path in all of OBGYN.

I would say maybe in all of medicine. A fertile battle, Alan DeCherney saying two months of research is enough. There's other things we need to be learning.

Marcel Cedars, editorial editor, E. Feinberg, editorial editor, disagree. Richard Scott saying we need more time to be in the lab for our fellows. We need to be doing bench-to-bedside research in the embryology lab to really advance our field.

Thomas Falcone saying we need to be doing more research in our training. We can't shorten training. And of course, we have the REI white paper on this topic, signed by ASRM and SART.

Many of the authors of that, Eduardo Harriton, Kate Devine, David Addison, Paul Linn, Erika Johnstone, are here in attendance at this meeting and really explores that whole topic and all about a dozen papers in FNS over the last two years talking about this. So what better place than PCRS to bring together this diverse panel of experts to talk about this. Now we're going to frame it debate style in a two-year versus three-year fellowship, and we've volunteered these people to which sides they will take, and at the end they can tell you what they really think, but for debate purposes they'll be arguing their side.

But it's really a much more complex issue than that, and we'll hope to delve into some of those things beyond two versus three years. So let me get right to it and introduce our speaker. On the third year or three-year fellowship side, we have Hadi Ramadan sitting right next to me, very bravely as a third-year fellow from Harvard Mass General volunteering to have this debate.

Thank you, sir, for doing that. We have Dr. Tia Bay Jackson. She's from RMA New York, an assistant professor at Mount Sinai.

We have Dr. Ebby Stewart. She's professor and program director at the Mayo Clinic, so we have a program director giving her perspective on fellowship training, very appropriate. Dr. Sammy Estevez from RMA New York, and we have Dr. Amanda Adelaide.

She's a founding partner and medical director at CCRM Chicago, and we have Hugh Taylor, chair of OBGYN at Yale, and of course past president of the American Society for Reproductive Medicine. So we have a very diverse panel of different perspectives and different voices, and I'm hoping we can explore this in a way that only the friendly confines of a meeting like PCRS would allow us to do. So I'm going to start with the two-year side.

Why should we change? So two-year, I'll hand it over to you to open the debate. Thank you so much, Dr. Hill, and thank you to everyone for being here, Fertility and Sterility, and to PCRS for hosting this amazing discussion that we are about to have. So we've all arguably entered the best field of medicine, really, to provide care for a really unique patient population with a variety of complex medical conditions, but unfortunately, we are not the only people within the broader medical community that sees the potential of this amazing field.

We can all agree that the number of REI fellows being produced per year is insufficient to treat the number of people who are struggling with infertility, and the question is whether we are going to turn to APPs and up-skilled generalists to address this need, or whether we want to create more talented REIs. I assume the majority of the audience here and those listening would want to increase the number of REIs as well as I do, but increasing the number of fellowship-trained physicians, and quickly, by doing that, we can potentially head off the encroachment and instead turn the future of REI into a more expansive field, allowing patients across the country better access to care. I posit that reducing the fellowship to two years instead of three is one of the primary means by which we can go about doing this and achieving this.

The most common rebuttal that people will put forth when talking about a two-year fellowship is that a shortened fellowship does not provide sufficient time to do adequate research. I think it's about time that we define what adequate research is, because the last time I checked, PhDs need upwards of eight years to do adequate research, and when you look at ABOG guidelines and everything else that's actually in publication, they do not explicitly mention us becoming physician-scientists. As a current fellow who's chosen to stay in academics when I graduate in a few months time, and who's already completed 20 research projects, six publications, over eight manuscripts, and many more in production, and several other presentations and conferences at conferences across the country, I can confidently say that two years is enough time for research.

That's not even counting what I'm working on right now for this upcoming ASRM. So, by decreasing the length of fellowship, we would increase the number of fellowship positions available, and per the white paper which we were discussing, and like we said, a lot of the esteemed physicians who contributed to that are here, there would be an increase from about 55 fellowships positions to about 73, which essentially addresses the number of qualified but unmatched candidates who are also mentioned in that article that are going through the match process each year. The alternative is to being proactive about increasing the number of fellow fellowship positions is that over the next 10 years, there'll be a contraction within the field and a degradation of the roles of REIs.

Assuming that REIs will be retiring each year, then our numbers will continue to dwindle instead of build over time. What we're really doing is gatekeeping our field out of a fear of losing our positions and exclusivity instead of helping to protect our specialty and make it grow. We need to stop living in a space of stagnation and fear, saying we will get to it.

We'll have more time. We'll do that next time. The time is now.

We need to be proactive, forward-thinking, and innovative if we are going to protect, enrich, and expand our field instead of sitting back and allowing cracks to develop, further harming our positions, and allowing other providers, companies, and technologies to take what we hold so dear away from us. So, you know, in conclusion, I just want to end just saying that without shortening fellowship, we are unlikely to be able to address the care issues that are so important to us in a really meaningful way, and we'll have to delegate responsibilities or let that significant gap remain and expand. We need to do something instead of do nothing, and by reducing the number of years that people will be in fellowship and spending those two years they would have in a very high-quality training, we can take that first of many steps needed to increase our cohort and provide even more care to patients in need.

Thank you. We'll go to the con side and to the three. Why do you disagree with that argument, Dr. Stewart? Well, I'll start with the point of agreement, and I think saying that we practice in the best field of medicine is right on.

That I think, in fact, that we're here at PCS, and the theme this year is innovation and integration. That is what makes REI an exciting field, and I can tell you that it's not only performing research, but evaluating, carefully integrating the research findings into the field is what makes REI different today than when I trained. Now, I didn't train in the dark ages of REI, where people were going to the operating room in the middle of the night to get one follicle.

By the time I'd come along, we were using gonadotropins, but, yeah, it was a field change, but when I trained, we didn't have GnRH agonist, we didn't have GnRH antagonist, and both of those changes have been incorporated in our field and let us get higher egg yields and better performance. When I was a fellow, we did a lot of tubal surgery because the optimized IVF pregnancy rate was probably about 10% then, and it's an accumulation of a lot of research, evaluation of research, and incorporating the things that move the field forward that are important. If we look on the laboratory side, we didn't have ICSI.

I remember a couple where they'd had their first baby because he had 50,000 sperm, and he came back a couple of years later to have another baby, and I go, 50,000 sperm? That's great. We've got more than enough to do IVF now that we have ICSI, that we have pre-implantation genetic testing, blastocyst culture, egg freezing, and all of this has arisen not only from the research that we do, but from the evaluation of the pros and cons of those research. I won't go through the list of things that we used to do that have now been proven not to be useful, nor will I go through the list of things that have been proposed innovations that hasn't turned out to be true, but I think that the purpose of a three-year fellowship is not only to get the breadth and depth of the clinical field, but to understand the breadth and depth of the research field and to understand how to incorporate all of the things that we are confronted with daily and weekly.

And again, at this meeting, we've talked about AI. Without being given the tools to evaluate the research, it's important. And I can tell you, I didn't learn a lot of my research lessons till I started doing it.

I had had three courses of statistics, and it wasn't till I got my own data and looked at it and realized that the published paper had been done wrong because, again, grappling with these issues on your own is important. So, I believe moving in the direction of keeping a three-year fellowship because it gives us the training to allow the top of the REI pyramid to function optimally is important. So, Dr. Stewart, I have a quick follow-up question before we go back to the two-year side.

The main principle that's driven this discussion is this idea that there is an increased demand, and we don't have enough access to the care that our patients need and deserve. And so, we have to find some way to meet that, and this is one of the solutions to address that. But not everyone necessarily agrees with that statement.

Do you, as the three-year side, agree that there is a problem that needs to be addressed, that there is an issue with training more REIs to meet this demand? Well, I think that the issue is, from my point of view, we need more strong multidisciplinary teams. And so, we do need the REIs at the top of that training pyramid to have the skills to lead the team, but I think we can better deploy the workforce. In fact, in our office, we have a nurse practitioner, we have an ultrasound tech, we have a physician's assistant, that I think a lot of people going into the team and each practicing at their optimal ability is important.

Great. So, both sides agree that we do have a challenge, a problem that we need to solve. So, back to those who are advocating that a two-year fellowship is the way to meet that demand, at least in part.

So, first, I love both points about access to care and also about improving and considering the breadth and depth of the intellectual challenge and rigor that it is to be a reproductive endocrinologist. So, I do agree with those general points. I'm going to bring this to... I'm going to bring up an economic argument, and I don't have an MBA, so don't judge me, but... So, I'm thinking about our current REIs in the room and our future REIs who are in the room, and I'd like to do a thought experiment.

So, imagine you have a generalist or, I think, now specialist OBGYN, okay? So, fresh out of residency, they get a salary of $250,000 per year. So, in three years, they'll make $750,000. Imagine a two-year fellowship with a salary of $80,000 per year, and then let's imagine that they're going to match and... or not match... they're going to get a first job getting, let's say, $400,000 as a salary.

So, in a two-year fellowship, they'll make $160,000 followed by $400,000. So, you know, if I do the math right, I believe that that's $560,000. And then imagine a three-year fellowship where somebody is getting $80,000 a year for three years.

So, at the end of three years, they've made $240,000. And so, there is an economic disadvantage for each RE who's going through a three-year fellowship. And it's not just the absolute numbers.

When you are pressed to have sort of a restrained or restricted salary to, let's say, $80,000 per year, it's hard to pay back your medical school loans. You're deferring those for longer. You're accumulating interest during that time.

And you're not making life choices, such as, you know, maybe purchasing a home, building your family during that time. And also, you're not making your money work for you necessarily. If you have $80,000 versus, you know, $250,000 per year or $400,000 per year, you might be more willing to invest and make that money work for you.

So, it's not just a differential of, say, you know, $500,000 between a generalist after three years and a fellow who's just graduating. It's the investment and the life opportunities that can be missed during that time. Furthermore, from a program perspective, a two-year program would be more cost-effective, right? It would just simply cost less to train somebody in two years over three years.

Now, I can't promise that if we went to two years, every program would redistribute or reallocate funds to increase slots, but I certainly hope so. And furthermore, it's possible that if a program is less expensive, there might be some clinics that are on the fence about opening a REI fellowship that will say, hey, you know, now that it's only two years, I think we can afford it. And that might open up even more slots than we initially anticipated.

So, I think that there are economic arguments both for fellows and also for programs to shorten to two years. Thank you. That's actually a really good argument and one that I don't think has been fully explored in these studies that I cited is that economic, almost you could say usury or price that those programs are getting those third-year fellows for.

So, that's a very interesting angle to it. So, from the third-year side, how do you reply to that? What's your main argument for support of the three-year fellowship? Thank you, Dr. Hill. Thank you for having us.

So, regarding the both points, first I'll start with the rebuttal, but regarding the extra funds that we would have, there is no guarantee that these funds would go to a third fellow, increasing the number of fellows across the nation. It's possible, but it's not a guarantee. The other thing is about the economic situation of the fellow themselves.

There are other ways of that third year becoming a little bit less expensive and, for example, we could address the ABOG fees, which are about six to ten thousand dollars for our board exams, right? We have moonlighting opportunities. We can do more moonlighting opportunities covering GYN, covering other calls. Housing, subsidized housing for the fellows.

So, all of these things might reduce the cost of living instead of truncating the training. But that takes me to the point of TRACS, which is I want to talk about what we lose if we have a two-year fellowship. And I will start with the surgery track.

We have seen huge success across the United States with the surgical scholar track. Fellows are applying and aiming for these fellowships. They're completing the track.

They're becoming reproductive surgeons. We see them joining academic as well as private practices and the value of the reproductive surgeon is well known. Every practice has aimed for at least one fertility surgeon in their practice and in order for the patients to get a well-rounded care rather than be referred to MIGs who do things differently.

This track is spreading and needs all three years of exposure. If we lose surgery to others, we lose the reproductive surgery society, which is an important part of our field. But that's just one example.

Another example, which Dr. Hill alluded to, is the skill set, which is embryology. We are spending less and less time in the embryology lab. If we want to really specialize in just ART, we need to be more knowledgeable about embryology.

There is an extremely high value in knowing how to counsel patients on their results by knowing the complexity of fertilization and lab outcomes as we saw today. One example is the RMA New Jersey program, which has an HCLD track for its fellows. This gives an REI an invaluable skill set that helps them to not only counsel patients, but to open clinics on their own increasing access to care.

To know how to do quality assessments and control, they know how to build a lab, how to maintain it, and how to give the best care possible to our patients, especially when results are suboptimal. IVF is under attack, as we saw in Alabama. We need more REIs who know how to defend the field by knowing the literature, knowing how the lab works, how to use certain language to fight for our patient rights.

This would not be possible with limited skill sets. We would not be able to be independent physicians and we'd lose more what we have fought for so hard to gain in our field. We need to empower REIs.

I hope in the next few years we see more emphasis on embryology skills so we have the tools to progress, expand, and fight for our patients. Oncofertility is another example. We're seeing huge progress over the past few years and it still is in its infancy.

The exposure to these patients would be suboptimal in only two years. So we'd end up with minimal understanding and providing substandard care. Another group is the LGBTQ care and donor programs, which is another area that's evolving at immense rates and needs us to be experts to provide the best care possible.

At five percent of the population, as they said in the paper, can we adequately be exposed to that population enough to give them the best care? Genetics is evolving. Should we or should we not transfer that mosaic embryo every single time people ask? Gene editing. Are we heading towards a designer baby world or a world where we have babies immune to certain diseases? These questions can only be answered by REIs.

Advocacy is another one. Advocacy for minorities, advocacy for underserved, advocacy for IVF in general. We see fellows on social media engaging in societal issues and fighting for our patient rights every single day.

In 20 years, if we have a very narrow skill set after doing only two years of fellowship, we have minimal understanding of the literature who's going to know how to advocate for our patients with different needs. In conclusion, if we do a two-year fellowship, we would move bit by bit towards only one skill set. We lose all the skill sets I just mentioned.

We cease to become experts and we can easily be replaced by anyone who trains for a few months doing egg retrievals, embryo transfers, and relies on chat GPT for protocols. In 20 years, yeah, in 20 years, we would lose our field to others and our fellowship diploma would be a mere participation award that we hang on the fridge. All of this is bound to result in substandard care.

It might solve the immediate problem of access to care, but it would be substandard care for all. My favorite thing about involving fellows in these debates is they come out swinging. So, Hugh, I believe you may have trained under the two-year system.

Now, I was supposed to be a three-year and I got six. My fellowship ended up being five. So I advocate personally for the five-year because it worked for me.

But some could argue you've been relatively successful with your two years that you did. So tell us why you advocate for that side. Well, actually you make a very good point.

You know, I stayed at the same place where I did my fellowship and for those of you who heard my presentation here this morning at PCRS, I'm still trying to get that thesis right. So the 30-year fellowship, I may quite get it done by 30, some 35 years. No, I think the point is we shouldn't be talking about how long it takes to do something.

We should be talking about what skills we need to learn, what competencies we need to get out of a fellowship and then figure out how much time it takes to learn that rather than the other way around arbitrarily saying two or three years. In the old days, we did have two-year fellowships and one year of that was research. We learned all of clinical REI in a single year.

And a matter of fact, if you'd done a lot of research before your fellowship, you could get permission from the board to do a one-year clinical fellowship. That was all we thought that it took to get adequate training and you'll see many of the leaders in the field. That's how much training they had.

And it's not, there are new things in the field today, but there was a lot in the field back then that we don't do now. We were the laparoscopic surgeons. There were no MIGS fellowships.

We were the leaders in the tough endometriosis surgeries. The first LAVHs were done by REIs. We had a lot more surgery training and you could make the argument that that's really what takes the most time seeing enough cases.

You know, can we think about training people more efficiently and effectively? Do we really need to do 2,000 intrauterine inseminations or how many vaginal ultrasounds and how many egg retrievals do we need to be good at it? In the old days, we did the pediatric adolescent gynecology as well. There was no PAG subspecialty recognition. That was all us.

We don't do that anymore. We have specialists to do that. We had many other things that have moved away from the field.

So in some ways the field has even gotten less complicated and less complex. If we could do it in one year in the old days, certainly I think we can do it in one year today. We really just need to think about what skills we need to learn and how many cases and what sort of competencies we need to learn to do that.

The other thing is a one year of research and a three-year fellowship does not make someone a professional researcher. It's a great start. We can learn a lot, but you really need more time than that if you're going to go on to do research for your career.

That's what the Warherd and the RSDPs and the K awards are for. That's why they have those because one year after fellowship just one year of fellowship rather is just not enough time. I could even argue that what we really need to do for people going out into clinical practice is to know how to interpret the literature and know how to critique the literature so we won't fall for every new paper that comes along.

We'll realize what its limitations are. And I'll argue that if you spend your one year going down one rabbit hole and investigating one area of research, you may not understand the rest of the field of research. Whether it's epidemiologic research, clinical trials research, basic research, or translational research.

Those are all different skill sets and we really need to train our fellows how to critique and understand many different areas of research pursuing in depth one very narrow research project doesn't get you even that training to be able to critique the literature. So we used to do it in one year. I think we could do it in a short time again.

The field in some ways even shrunk. I think a two-year fellowship would be sufficient. Great, thank you.

I like the reframing of the whole debate from not how long should it be, but what are the skills that we need to train and how do we how do we best accomplish that? Before we get to our last argument, I just want to welcome our online audience. We have several hundred people online virtually registered. Please put your questions for our six expert discussants into the chat and we'll answer that.

To our on-site audience we're going to open it up for questions and discussion here in just a second and I imagine we're going to have a very robust discussion. Tia, you get to round us out with the final argument before we open the crossfire. Go for it.

Absolutely. Well, thank you so much for having us. This is such a fun thing to really talk about and explore.

And I'm grateful for it. You know, I think that even though we've been to the two-year fellowship program now, I think the complexity that we see now and the increased volume of what we see even just in the past five years how our field has really just grown, it still requires more of us. I don't think that moving to two years would actually get us to where we want to be.

So I don't really advocate for truncating the training. I do agree that our current system needs more support to meet the needs of not just our current patients, but our future patients as well. You know, as physicians, I want to make sure that we're training skilled and wholly trained REIs.

Instead of shortening programs, you know, I really believe that there's a grave need to increase the number of fellowship programs. You know, currently I reside in Brooklyn, New York. A single county, we call it a borough in New York, but it's a single county that's home to three million people.

And there are a number of OBGYN residency programs in the county and not a single one has an REI fellowship. So within a large urban center, we still have an access issue. There was attempts to have a program in Brooklyn, and I don't even think it was able to make it to graduate its first fellow.

Similarly, Chicago, a city, maybe third largest or so in our country, also has about three million people and numerous, you know, very well-ranked academic institutions and private fertility clinics, and still a single REI fellowship in a city that large. I think this is, you know, there's an immediate need to empower and support OBGYN departments and to allow them to invest in ACGME REI fellowships. You know, any failure or closure of fellowship programs or disruption of whole REI departments at this point in time with the need that we have is a significant failure of our field.

I think we are all accountable in that regard. There's a lack of collaboration between departments. There's no cross-institutional research opportunities and even mentoring for program directors and people who want to endeavor in this way.

So I think that is something that we really can't ignore. There are so many opportunities for collaboration research funding with these kind of private-demic, hybrid ways of collaborating with private groups. And so I think that also serves to expand opportunities for our field.

There's so much discussion about creating tracks in REI fellowship. But I think if we want to decrease the overall length of training, we need to look back to tracking in OBGYN residency programs. This is something that's been discussed for years.

Could we potentially shave a whole year or change the way that the training is done so that, you know, fellows are entering fellowship a little bit better trained? You don't need to deliver 500 babies to know how to do ART. And so, you know, if there's a way to track residents, if they're accepted to residency, or if they come into the field knowing what they want to do, I think that's an area that we could really focus on that doesn't have to take away from their subspecialty training. Lastly, you have to remember that not all REI fellowships are created equal.

So when we talk about blanketly, you know, cutting the number of years of training, some fellowship programs are really going to suffer. You know, a number of academic programs probably do less than 500 ART cycles in a year, whereas, you know, some robust programs may do that number per attending. And so I think by limiting their clinical exposure in a blanket way, saying that all programs would go down to two years, really would be a mistake.

You know, one of the things that we haven't really discussed much is our allied health partners in terms of how do we increase access. I think one way is to kind of unburden the highest person in the skill set with some of the daily activities, ultrasounds, IUIs, and in allowing more mid-level providers in to help us in this way. It's not a takeover of the field.

It really is a reallocation, a redistribution of your skill set. And I think that even that may help to unburden our fellows in a way to free up their time so that they aren't monitoring every morning five days a week, seven days a week in some ways, with ultrasounds and doing things that, you know, just it also allows us to make sure that they're not having burnout and makes our field more attractive. I could go without saying, but, you know, we would want to have a legion of well-trained reproductive sonographers which could really kind of free up our time.

There's so many other things that I could talk about and I'm sure we'll get to in the questions portion. But again, I think our real thing is we have to think about who we want to be as a field. If we cut research from the fellowship programs, our field will suffer.

The majority of research coming out right now comes from fellows and from fellowship programs. And so we really have to be able to think beyond the immediacy and where do we want to be as a field. Great.

So as we move into the questions, I'm going to ask one just to round out the framing of the discussion. And this is particularly to Dr. Stewart and Dr. Taylor. One is a program director and one is a department chair.

It just seems intuitive that if we cut fellowships to two years, we can take that extra money and it will go to funding an extra fellow. So first, Dr. Stewart, just what are the practical realities? Where does GME money come from? If you were to take that to your hospital and say, this is the plan, would they say you can keep that money and automatically use it? And then I want to go to Dr. Taylor as a chair, just describing the realities of how that money flows and what decisions have to be made. I've already asked that question and the answer is it disappears.

There's no way. It depends on the institution, of course, but it often will disappear. Well, and probably get applied to some other program that wants to start a new three-year fellowship.

And for those who aren't in academic institutions, can you just take 60 seconds and elaborate on that? So where does the GME money come from? Who's in control of that? So if you say this is what we're doing, who's the one making that decision that that money goes elsewhere? Who do you have to convince? So it's at the level of the dean. And so again, OBGYN is already a less than powerful force in most medical schools. And so I think that if we decide to go to a two-year fellowship, then that money will be reallocated to the surgical field.

Dr. Taylor, would that be similar at your institution and your experience with other chairs? Yeah, ours is a little different structure because our hospital and medical school are separate and the money goes through the hospital. But, you know, they would, they're always looking for ways to cut us. So it'd be safe to say that in most academic institutions, it would not be a given that the fellowship, the division, would get to keep that money and invest it into training more fellows.

For most, I would imagine that's the case. You'll lose the money. Great.

Dr. Quaz, the incoming president of PCRS. I think you were first in line, if I'm seeing correct. Thank you.

Yes, Dr. Quaz from Shady Gore Fertility in San Diego. So I sort of have some thoughts about this debate because it sort of blends into the debate about whether OBGYNs should do egg retrievals and whether they should do like what we do. And sometimes this debate reminds me a little bit of the anesthesiologists getting all up in arms about the fact that more and more CRNAs are doing anesthesia and they're providing those services at maybe, I don't know, a quarter or a third of the cost of an anesthesiologist.

And rather than creating artificial barriers and just making it impossible for that to happen because you're worried about your own existence, we should prove why we are superior. Because, you know, at the end of the day, you know, like I was a generalist for two years after residency. I did laparoscopic hysterectomies.

I like did everything and then I came into fellowship and I was doing a polypectomy and my attending was like, oh, don't, don't, don't. And, you know, we like to pretend to everybody that we have these magic hands that only us can do egg retrievals and embryo transfers. And nobody else can do that because we have these magic hands and they come with a three-year fellowship because we sit through the fellowship.

And so maybe what we should do is have a track for the more practical clinicians who are the people who do practical IVF and they're very proficient at it. And there may be a longer track for the people who want to go into an academic career and want to become people like Dr. Stewart and Dr. Taylor. So that's just a thought.

You have a comment or reply to that? We actually discussed that, Dr. Kwas. Like, for example, let's say in a world where we have a two-year fellowship, right? I'm still in character. But let's say we have a two-year fellowship.

A lot of people will just choose the two-year fellowship. And but that's a message from our society saying two years is enough. But the whole discussion was two years is not enough, right? For, like, there's a lot that we need to do in three years.

But if we say that you could do two years or you could do extra, we're saying that, oh, two years would be enough if you just want to do this. We're saying that, no, even when you'd want to do just ART, you need to do three years for the research, for the embryology lab, for all of these things. So that option, just giving it, would be sending the quote-unquote wrong message.

Yeah, and I think the less, the less, or the important issue is not can somebody else do an egg retrieval? Probably they can. But can they sit there when you've got this complex genetic report about which embryos to choose and the limitations of doing PGTA, or you've got a sick fertility preservation patient who's anticoagulated, and you're trying to get them to a successful egg retrieval. That's increasingly what the REI needs to be doing.

And if somebody else is doing the IUIs, you know, when I was a fellow, all the fellows did all the IUIs. And then for billing reasons, we went to all the attendings doing the IUIs, and now our nurses do the IUIs. So I think there are certain procedural things that we can train people to do.

But I think understanding the science, integrating the medicine, doing the complex decision-making is where we really need to have a substantial foundation and training. Yeah, and I think that when we take our boards, ABOC says we should become proficient consultants for generalists. Like we should be able to advise a generalist over UIN on these complex things.

The question is just do you need two years or three years for that? Thank you, Dr. Cross. Sir? I'm Paul Magarelli. I work at Kindbody, and thank you.

First, I think the premise that learning begins and ends in a three-year fellowship makes no sense, because in medicine, I'm at it about 130 years now, it feels like. I still learn something every day from these kind of meetings and from other people. A multidiscipline, I mean, as Alex was saying, the idea that three versus two, and Dr. Taylor was saying, it's what you want to learn versus what you are going to do.

To me, access to care today is way better, or I'm sorry, is more needed than this concept of what's it going to do to our profession? There are millions and millions and millions of couples, people who don't have access, and that's because we don't have enough of us around to do the job. Getting more of us now and then taking lifelong learning as a commitment you made to become a physician, to me, that's the goal. So, getting us to a two-year program will get us to, and by the way, I'm from a two-year program, so I kind of feel like I know a little bit, but getting us to a two-year program, if that does get more people on the street taking care of patients, well, that has to be a good thing, regardless of its implication for the knowledge, because the knowledge that we want to acquire is lifelong.

the other last point, and I'm sorry because it's a lot of things, was how many of the residents today, I'm sorry, the fellows today, get access to numbers of procedures that they're actually going to do? In other words, are you doing 50 to 100 before you graduate? Whereas some of our fellow graduates have done five transfers and two retrievals before they get their degree from a three-year program, saying they're reproductive endocrinologists. So that debate, I mean, is really what needs to be had. So anyway, thanks for bringing it up.

I really appreciate it. Do we have any reply from the panel? Can we have the names of those programs that will let you graduate after doing five retrievals? I don't know. I don't want to look into this.

I don't know of any like that. I'll start kind of at the end. So when you graduate a fellow who maybe did not have enough clinical exposure, it really shifts the the I guess the responsibility onto that first job that they take.

And this is even a challenge now in terms of some clinics don't want to assume that responsibility. Some people know that it's going to just be part of what you do, but financially you're at a disadvantage of not having someone who's as well-trained. So to even cut them further, I don't think would be so much helpful.

You know, in terms of access, you know, somebody, we all are very passionate about increasing access and meeting the need. You know, there are more things than just bodies that are needed. You know, we actually do not have adequate geographic distribution of the current REIs in practice.

We could be doing so much more if you'd be willing to go practice in a suburban or rural area or a different state, but that's just not the reality. We're putting more people in the same cities, in the same geographic locations, and it actually does not significantly improve access except for a small few. So that's something that we really have to be honest about and address as well.

Another huge issue with access is finances. We have, what, maybe 20 mandated states so far out of 50 in the country. We still have the majority of people who have a need, cannot financially afford the services that are sitting right there in their city.

And so if we talk about access, we really have to make sure that we're including advocacy and really taking insurance companies and our federal and state and local governments to task to make sure that people can actually afford what is sitting right there in front of them. Very well said. This alone will not solve the access issue.

I think that's very clear. But that's not today's debate. Before we get to Dr. Addison, Dr. Estevez, did you have a comment to that? Yeah, I just wanted to add on the comment about the lifelong learner.

I think it's, you know, a little short-sighted to just act like once you're done with fellowship, as everyone's been mentioning, you are finished learning. If you talk to a generalist or if you talk to an REI or if you talk to, you know, orthopedist, anybody, everybody is going to tell you that your first year out of training is going to be the hardest year of your life because you're actually learning how to be a doctor. You're implementing things that you've had in theory, that you always had somebody watching over you, telling you what to do.

So pretending like two versus three years, you're going to come out that much better. There are positives and negatives to each side of this argument, but everybody is going to come out scared to do their first orthotistroscopy by themselves, even though they've done a thousand and they could do it with their eyes closed. Everybody is going to have nerves and learning and a lot of growth to happen and that's going to extend throughout their career because what brought us here is the fact that we want to keep learning.

We want to keep making change and we want to keep doing things and whether you have a two-year or a three-year fellowship, that isn't going to be dampened in any way. Dr. Addison, you've seen this play out for a while, sir. What are your comments? What are your questions? Well, the first comment is what a wonderful, wonderful conversation, discussion.

And the second comment, I think it's absolutely critical to have it because I do think we face an existential threat to our specialty. And the threat will not come from much of what's been discussed so far, but it's going to come from all the external financial pressures that will absolutely shape our specialty. And if we don't think that these financial pressures will shape it, we can just look at what our specialty looked like in 2010 and what it looks like in 2024.

And if you don't think that's going to continue, then you're not really going to be ground-based in what you need to do. So this is a great discussion. I think we need to take a holistic approach because there have been so many excellent points made, two years, three years, excellent points.

But I think we really need to determine what is it we think REIs ought to do. I'm a reproductive surgeon. I learned surgery as a fellow.

There are very few REI fellowships today could claim they trained reproductive surgeons, right? And what about genetics that's coming? Are we going to let that all go to someone else or is that important enough because it's going on in our embryology labs that we need to know a lot more about it? What about the pediatric gynecology, which is probably gone now? What about menopause, which is becoming very important? So along the lines of what others have said, I think my personal view is my personal view, but I think we need a conversation as our entire specialty, not just the academics who are sort of controlling some of this and not just the clinicians who are living in the financial world, but all of us together and say, what do we think we should be doing? I personally think that ART is here to stay and many, many things are going to come off ART. I'm not so sure reproductive surgery, other than some of the simple stuff, is really in our wheelhouse anymore. It was, but I don't really think it is now, but that's for somebody else to decide.

But I think we need to decide what's the universe because you can't whack a mole for everything that's out there. There's no way any one of us can know everything. So the first thing is, what do we want to be? The second thing is to create a body of people that can do that.

What kind of training do we need? And as we've heard over and over, the real training, first of all, is to find the right people who are committed to lifelong learning. And with all due respect that's here, not every physician is committed to lifelong learning. We've got to find the right people who come in and say, I know I'm hardly going to know anything when I graduate, but I want to get the building blocks that I know statistics, I know how to read a paper, I know how to do some basic research, I care about that, enough that they have a foundation.

And then I do believe, in order to meet the demand in a two-year core, but then a third year that could be optional for genetics or, you know, menopause or anything that's under clinical epidemiology, basic research, pick it, and you could get maybe a certificate of special competence in that. Or perhaps even an MBA in managing and running IVF systems, which could also be important. But I think we need to decide what we want to be because honestly, I think the ocean is too big to do everything that we've sort of done before, except the fact that it's going to be lifelong learning, and then get the right people and really give them the right foundation to do that, and then support them as they go through their career.

One last comment. I've been in practice one year in a group. I was the only RE in the group.

I was one of the first REs, and there were eight OBGYNs. And I was sitting in the doctor's lounge with these other guys one day, and a doctor had been in practice eight or nine years, and everybody thought he was a fabulous OBGYN. They're all OBGYNs.

And he said to me, well, he said, boy, I've just had a couple of tough patients. I'm finally figuring out what it takes to do to be a really good doctor. He'd been in practice seven or eight years.

I said, it took me five or six years to learn what to do. And I'm sitting there. I've been out about eight months.

I said, God, it's not going to take me five or six years to figure this out. I got to tell you, I think five or six years is a short period of time to learn what you need to do. So it's lifelong, and that's what makes it so fabulous.

Thank you. Thank you, sir. We've got about 13 minutes left, so we'll have a couple more questions.

But anyone on the panel want to have any replies to what Dr. Adamson said? I do. So I agree with that point. I would just say, I think about maybe we should be reframing the question as, you know, what are we trying to measure? So not only who are we as a field, but how are we going to measure that? I think that there's at least a few buckets.

One would be like a very kind of numeric, kind of corporate KPI type system, right, where we're looking at yield, you know, number of IVF cycles done per physician, right, which was in the white paper that we're discussing. And, you know, that's a reasonable metric, right, but that's a very kind of concrete way of thinking about things. And, you know, the numbers are there.

We could kind of shuffle around fellows, years, time. We could make it work. Very likely we're going to continue to need APPs to support us and OBGYNs.

That's easy. We could think about is the goal of our field to really engage with our patients, right? Like I can tell you, I think most of the REs in the room can say we have patients that complain that, you know, they don't get to hear from us. They don't get to talk to us.

They feel left out of the decision making, right? We're treating other humans. Like it's what I love doing that. And I think as a field, we're getting away from that.

And I don't know that increasing the number of REs by 20, 25 maybe per year is really going to get us to that goal. So we kind of could reframe the question of how do we get patient-centered again. A third thing to think about is what Dr. Stewart raised, which is are we as a field about innovation, which is also the theme of the conference, right? And if we're about innovation, then we have to think about this question of how long the fellowship is in terms of what are we giving fellows to inspire them and to be prepared to ask the best questions that will require lifelong learning to answer.

And so I agree with Dr. Adamson. And I would just say I think as a field, we should also be thinking about what's our goal and how are we going to measure it. Dr. Harrington.

So I'll make a quick comment and then I'll ask a question. I think when you think about what are we as a field, which is ultimately the question that we're grappling, we're drawing the circles around retrievals and transfers and we're the only ones that can do that. But when you look at embryo transfer, the data shows that fellows are the same as us.

And we're not egg suckers. We're like Dr. Stewart said. We're reproductive experts.

We're here to answer complex questions and really figure out how to help patients. And we're consultants to other people. So in my mind, the best example of that is we graduate tons of fellows every single year that don't do a single embryo transfer.

And then we say you need to go out there and do the embryo transfer. So that I think is an important part of the focus is really defining what it is that we are and who do we want to be and how do we want to work with all of the people that work with us to deliver the care that our patients need. And if we don't define that structure of what we want to do and how we help people, it's going to be defined for us by people who are not physicians.

And that is a real challenge. We need to figure out which patients are simple enough and protocolized enough that someone else can help us take care of them. And then which ones are complex enough that we need to be there.

And when do we escalate in the same way that when a midwife is doing a delivery and the baby's not coming, they call someone else to do a forceps delivery. And when you have triplets on the labor floor with preeclampsia, you call an MFM and say, hey, should I deliver them? Should I start MAC? What do I do? And there's a clear set of guidelines of how you escalate care to talk with the experts. And if we're not part of that conversation, then external forces are going to drive that conversation for us with the wrong incentives and not necessarily the best interest of patients.

So I think that's an important thing to think about as a field and something that we have to grapple with. You know, in regards to the two to three year fellowship, my question for the panel is who should decide? Like, you know, we have 1,200 or 1,250 board REIs across the country. Some of them are in practice trying to hire to locations that need help and they can't.

So they clearly want more people to come to the field. You have academic centers who rely on fellows and who, you know, like having people who work very hard for them and they want to have them around more. So, you know, people have different interests for very good reasons.

So who should be the ones that are deciding on who as a field should make that decision? Is it both the majority? Is it the people who train them? Is it ABOG? Who should make that decision? Great. Thank you, Eduardo. Do we have anyone on the panel who would like to answer that? And then we'll have time for one more question from the audience.

So if one more person would like to come to the microphone. Do we have any replies to Eduardo's comments or we can let them stand as they are? Very excellent. Go ahead.

My one thought on this is to your question more specifically is that it has to be a combination. We have to base this conversation in reality. There's people in academics who have their reasons for doing what they do and why they love what they do.

There are people who are in private practice who have their reasons for doing what they do. And they have two completely different perspectives, as you highlighted. And that's not just something exclusive to REI.

I have friends who are MFMs and they complain about the people at the academic center not understanding the reality of seeing this many patients in this sort of a setting. That is medicine. There's always going to be the academic side and there's always going to be the private side.

And for us to evolve as a field, we need to stop being at odds with each other and say that's them versus us. And we need to come together and do something that's productive so that any fellow, whichever way they go in their path of their career, which could be back and forth between either of these things, can be adequately prepared and ready to take on the challenges of each part of that. And then have a more nuanced understanding of the other side and not put themselves into these separate camps of us versus them.

We are all here together and we're all here for a singular goal and we need to keep that in mind, especially when planning about future spots and future, you know, just the general future of this entire field. And just very briefly, I think we all come together a lot more if we talk about competencies rather than arbitrary timelines. Let's talk about what a reproductive endocrinologist is and what we need to train and what they need to learn and then we can fit that back in to figure out how long it takes to learn all that.

I think we'd actually come to a greater consensus sooner doing it that way. Well said. So we're going to get to our last question here.

Panelists, prepare your final 30-second summary and you can say what you really think. If you disagree with this, I assigned you two randomly and you can change your mind and let us know, but we'll come to the final closing. Ma'am.

Hi, I'm Lisa Shanley, third-year fellow at Emory University in Atlanta. The three-year group arguing for the three-year fellowship mentioned that private clinics and private clinics that have the capacity to have learners should step up and try to create fellowships and really support growing the REI workforce in that capacity. And you also have argued that having a robust research opportunities and having, you know, the time in the research lab that is the predominant part of a third year of a fellowship is important and I imagine that most of the private clinics and private clinic clinics would struggle to have such a robust research opportunities even if they do have the clinical capacity and educational capacity to take on a fellow.

So I just was wondering if you could speak to how those two forces that are seemingly at odds might, you know, not necessarily be antagonist to each other. Well, I think we actually do it pretty well right now. You know, there's always going to be a need for a academic affiliation and that could be with a department that has a REI department or not.

You know, basic science research, I mean, we do early placentation research, we do genetics research, we do lots of different things. Also, as you know, Hadi mentioned, it doesn't have to be in a lab. This is a whole different fertile discussion, but, you know, it doesn't have to be bench research in a lab, but there's a lot of different robust research opportunities that can come out of these partnerships.

Obviously, a lot of it right now is clinical research and kind of outcomes and data driven, but there's going to be so much more that can come out of that, too. So I'm actually not concerned at all about expanding in that way, expanding with private or private programs and getting the research that they need. So we're going to come to our closing arguments and we'll see what our audience thinks.

I want to thank our online audience. I just want to highlight one question. We won't answer it, but I just want to say it because it's a global perspective.

This is from Mikan Motamedi. He's a fellow at the University of Toronto in Canada, and his experience reflects really a lot of the rest of the world. He says, what do we learn in two years that you learn in three? Like, what do we need to know that you're learning in that third year that I'm not, which is a good way of framing it.

It's sort of a reverse way of looking at it, but I do like the way that this discussion has been framed from looking at what are the skill sets and knowledges that we need to train, and how long does that take to do it is the second question, not as the first. So, Amanda, we're going to start with you and we're going to work our way down the table. Thirty-second elevator pitch.

What do you think? Oh, jeez. Okay. More just some quick thoughts.

One, I was in academics the last four and a half years and only recently moved to private practice, and I will say hopefully I don't think that they have to be at odds in terms of the goal. I think that there might be some motivations that are different, but I think ultimately we all want to see an improvement in access to care, and, you know, I know people from all over the country, and I think we're all pretty passionate about what brought us to the field. I trained at UCSF, a three-year program, of course, and I loved it.

It was the best time of my life, and, you know, selfishly, it was really hard to be on the two-year side because it's like I wish I could give that wonderful time to kind of everybody in the room who's a fellow, but I think it had to do a lot with, you know, the faculty that I had and my amazing co-fellows, and, you know, I think to Tia's, to Dr. Jackson-Bey's point, every program's a little bit different, and, you know, I think we do need to be cautious that not all programs are created equal in terms of environment, and so reducing the fellowship time might not benefit everybody in the same way. Hugh? Also, although I'm assigned to the two-year side, I really like the three-year fellowship. You know, I think some of the smaller programs may not be able to meet all of the training requirements in the two-year time frame, and maybe we'd actually end up losing some fellowships and diminishing the number if we went to a two-year fellowship.

We might actually end up cutting some fellowships that just can't train that quickly based on the number of cases they have. Second, I think it's great for our fellows to get the opportunity to see what that research is like. If you're in a two-year fellowship, you're deciding where you're going to go after a year.

You haven't had time to learn about research, and I found so many of our fellows over the years had not intended to do research, but end up loving it and going into an academic career, and I really want to make sure we afford them that opportunity. And then third, you know, I think it's important that people are trained, even if they're not going into research, and I must say, a lot of great research is done by fellows in academic institutions. We shouldn't discount that.

It really is an engine of growth and improvement for our specialty. But even if you're not going to do research, I think it's really important you know how to, as I said before, critique the literature so that you won't be duped into falling for each new paper that comes along, and that is something that really is best done in an academic institution, where people are doing the research and able to best critique it and see all the potential flaws, you know, limitations of research. So I really still like the three-year fellowship.

We can increase access by using more mid-levels and some of the other novel solutions that we've heard from from people here today. Sammy. I'm the only true two-year person on the two-year team.

But I will, you know, I want to end really more with a thought for everybody to take away. I think it's been made very clear that we need more people within our field. There's a lot of different ways to go about doing that, whether it's reducing the number of years of fellowship, increasing the number of fellowship spots, things like that.

But I think we need to be a lot more introspective than we already are when it comes to this. There's about 1,600 people who graduate from OBGYN residency every single year. Why are only 70 of them even trying to become REIs? What is wrong with our training in medical school and in residency that fewer people are seeing what an amazing field this is or even trying to become REIs? Why is there not more of a demand? We talk about a high match rate of, oh, there's 50-something spots and we have 70, so that's a really high percentage.

Great. Why is it not 200 people applying? Why don't we have that external force pushing us to grow the way we know we need to? And I think we need to really start thinking about how we might be kind of cutting off our nose to spite our face and making this a very exclusive club and preventing great doctors who could come and work with us and change the world from even considering this as a field to join. So I think even though it's not the most relevant thing to what we're talking about, I think it's something that's really part of the inception of the whole question here.

Great. Ebby. Yes.

So I think in many ways we're talking about the wrong things. I think we can teach a lot of people to do egg retrievals. I think we can, it's much harder to take somebody to talk through the menstrual cycle and how it works and how these medications impact it and what the equivalencies of various hormone preparations are.

So I think the field has become so much more medically complex that I still lean and support the direction of the third-year fellowship, but I think we need to start talking about some of the realities, and again, I think reallocating three-year fellowships to two-year fellowships is just going to get us fewer positions. Great. Tia.

You know, I've said it a million times during this presentation and as we were preparing, I do really think we need to go back to who do we want to be as a field. I think that actually is the next big discussion in the panel that needs to happen is how do we want to define our field? And I completely agree with Eduardo. If we don't do it for ourselves, it will happen around us.

I'm not as concerned with OB-GYNs, you know, doing egg retrievals as I am with them hanging a shingle and saying that they're a fertility expert, you know, and so that's really where I think our interest or our next kind of effort needs to really lie is kind of this reorganization of our field, and I agree. Then we can really decide what the training needs to look like and how we can adequately address that need. One thing that I do think in terms of the three-year program is so much of our life in medicine is running towards a goal, and you're running and you're running and you're running, and then you kind of fall off a cliff when you get your first job, and you have to figure the rest out.

You know, having the three-year fellowship, at least in a field like REI, allows you to slow down. That research year is a self-care year. It allows you to see something outside of your normal daily life.

You're expanding your brain in different ways. You probably get to sleep full eight hours and exercise and take care of your body, and that is actually what drives innovation. If you've ever been to Google or Amazon's offices, you can take a nap in the middle of the day.

Like, you have to be able to have that kind of brain rest in order to be someone who innovates, so I think that's another part that we don't often talk about is what it actually gives back to the fellows and how they can change the field by having that time. A wellness year. I love it.

Hadi, round us out. So, I don't have a stance on two years versus three years, but I'll just make a plea for the fellows. I think, I don't know who are the powers that decide these things, but there must be a, and someone who addresses our curriculum, because our field is evolving every single day, and we need to address the curriculum and not just do what they've been doing for the past 20 years, and please, also, for whatever powers, try to address the fellows' financial situation.

I mean, it's really bad, so. So, that's just my plea. Thank you.

Thank you. So, I'm going to make an executive decision. We're not going to take a final poll, as we normally would for a debate.

I think this is such a complex and nuanced question. It does it a disservice to break it down to a yes or a no vote for two versus three years. I greatly want to thank PCRS for, once again, partnering with Fertility and Sterility.

I want to thank the six of you. I have not been involved in a more passionate debate around this topic, and I appreciate that we could have such a wonderful professional discourse. Thank you for the audience.

This was a lovely Fertility and Sterility Journal Club Global. Have a great afternoon.