Portal de Periódicos da CAPES

The mismatch in supply and demand: reproductive endocrinology and infertility workforce challenges and controversies

2023; Elsevier BV; Volume: 120; Issue: 3 Linguagem: Inglês

10.1016/j.fertnstert.2023.01.007

1556-5653

Amanda Adeleye, Jennifer F. Kawwass, Anate Brauer, John Storment, Pasquale Patrizio, Eve C. Feinberg,

Ovarian function and disorders

Although the need for physicians is widely spread across the country in many specialties, there is an increased demand for physicians specializing in reproductive endocrinology and infertility (REI), especially in underserved areas. Over the past 20 years, the use of in vitro fertilization (IVF) has tripled (1Centers for Disease Control and PreventionART success rates.https://www.cdc.gov/art/artdata/index.htmlDate accessed: August 30, 2022Google Scholar). A part of the heightened demand stems from older age at the time of the first delivery; decline in sperm quality, resulting in more male factor infertility; expansion of insurance coverage, enabling greater access to care; increased Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) family building; and growing interest in fertility preservation (2Hipp H.S. Crawford S. Boulet S. Toner J. Sparks A.A. Kawwass J.F. Trends and outcomes for preimplantation genetic testing in the United States, 2014-2018.JAMA. 2022; 327: 1288-1290Crossref PubMed Scopus (14) Google Scholar). In 2019, there were 448 clinics, staffed by 1,351 fellowship-trained REI physicians, that reported clinical data and outcomes to the Society for Assisted Reproductive Technology (3Centers for Disease Control and Prevention2019 assisted reproductive technology fertility clinic and national summary report.https://www.cdc.gov/art/reports/2019/pdf/2019-Report-ART-Fertility-Clinic-National-Summary-h.pdfDate accessed: August 30, 2022Google Scholar). In contrast, there are approximately 12.2 million people experiencing infertility in the United States. However, despite the large growth of IVF cycle volume over the last 2 decades, it has been estimated that millions of people remain untreated and that the number of board-certified REI physicians has not grown proportionately to address this need. Not only are the absolute numbers of reproductive endocrinologists limited but they are also often regionally restricted to urban centers, making it difficult for people in suburban and rural areas to access care. At present, there is a large mismatch in supply and demand, and the need for more REI fellowship-trained physicians is one of the greatest challenges that the field faces. Collaborations with obstetricians or gynecologists (Ob/Gyns) and women's health clinics; the use of physician extenders, such as advanced practice providers; and leveraging technology are varied strategies to expand access to care. Additionally, rethinking how fellowships are funded and structured may help to reduce the gap between supply and demand in reproductive care. One tactic to improve the allocation of scarce resources is task redistribution. Recognition of the shortage of REI specialists may serve as a call to action for generalist Ob/Gyns providing annual well-women examinations to ask the following questions to reproductive-aged patients (4Infertility workup for the women's health specialist: ACOG committee opinion, number 781.Obstet Gynecol. 2019; 133: e377-e384Crossref PubMed Scopus (118) Google Scholar):•"Are you thinking about having a family in the next year?"•"If you have been trying to conceive, how long have you been trying?" Additionally, a proper infertility evaluation begun before initial consultation with an REI specialist may expedite the time to treatment and may potentially allow the REI specialist to care for more patients. Reproductive endocrinology and infertility specialists can work with local Ob/Gyn practices and women's health care clinics to establish safe treatment and monitor protocols for ovulation induction and recommendations for when to refer to REI specialists. Integrating general Ob/Gyn consultation into initial treatment could be more beneficial than consultation alone because patients who fail to achieve pregnancy with intrauterine insemination (IUI) can seamlessly transition to REI for assisted reproductive technology. National organizations, such as the American Society for Reproductive Medicine, can work with national women's health clinics (such as Planned Parenthood) to expand services such as infertility evaluation and treatment, especially in states where access to abortion is restricted and clinic infrastructure is already in place. Additional training in sperm analysis, preparation, and IUI can be offered at meetings, such as the American College of Obstetricians and Gynecologists, to expand access to care, and this may be especially beneficial to patients in rural areas. Another route to improve access to reproductive care is to enhance the use of advanced practice providers (APPs), such as physician assistants or nurse practitioners, for nonsurgical services. The use of APPs for appropriately selected new patient visits, morning monitoring, saline ultrasounds, or hysterosalpingograms may allow physicians to focus on more medically complex patients and procedures. When physician extenders are used, physicians should be readily available to step in as needed. The purpose of advanced providers is not to replace physicians but, rather, to work as an adjunct to help with better use of valuable time. Because the number of planned oocyte cryopreservation cycles has increased exponentially, this is an area where APPs could be leveraged. An APP could see the patient during the initial intake visit and coordinate ovarian reserve and other necessary tests to streamline the follow-up visit to the physician. The physician-APP dyad could work together collaboratively, with the REI specialist overseeing protocol choice, making medical decisions, and performing surgical components. The daily routine aspects of care would be led by the APP. This approach frees the REI specialist to focus on treating the disease and conserve expertise for more complex patients. Increasing mental health support in practices can also alleviate some of the burden currently shouldered by REI specialists. In addition to patient education, a large portion of the physician-patient interaction involves managing the psychosocial aspects of care. In addition to investments in staffing, investments in technology may improve the efficiency and delivery of care. Physician consultations with patients can be reserved for high-yield discussions. Online educational platforms can be used to supplement patient education and have been shown to meaningfully improve the comprehension of IUI and IVF, gain informed consent, and improve adherence to treatment protocols. Furthermore, artificial intelligence has shown early promise in the potential to reduce physicians' time spent making daily treatment decisions, although its clinical application is currently experimental. Ideally, additional hours gained with the use of technology can be used to expand the reach of a single physician by allowing for a greater volume of patients. Increasing the number of graduating physicians in REI is another strategy to expand access to care. The lack of consistent funding remains a major barrier to the addition of additional positions. The cost of educating 1 fellow for 3 years can exceed $450,000. Currently, fellowship education that is based in the university setting is funded at the institutional level and often funded by the REI division. Another option is to create relationships between nonuniversity-based REI practices and academic medical centers to create joint programs with shared teaching responsibility. Academic medical centers encourage the use of philanthropic fundraising to support additional positions, which presents major challenges, and partnering with nonuniversity programs may alleviate this burden. Partnering with technology companies, the pharmaceutical industry, or private equity-backed fertility practice networks may be another potential strategy to fund fellowship positions. This model has been employed by 1 network thus far, whereby the fertility practice entity provides funding for the fellow stipend, benefits, and other educational costs. The healthcare industry has largely been excluded from direct involvement with medical school and resident education to prevent the insertion of biases early in the training process. Educational funding can be a mutually beneficial gateway to improve the overall specialty. Private fertility clinics could contribute to increasing the workforce by incorporating long-term investment in fellow education into their mission (5Patrizio P. Albertini D.F. Gleicher N. Caplan A. The changing world of IVF: the pros and cons of new business models offering assisted reproductive technologies.J Assist Reprod Genet. 2022; 39: 305-313Crossref PubMed Scopus (11) Google Scholar). Some practices have already adopted this model by directly funding fellowship positions. Using a shared funding model, it would be important that any privately funded fellowship program neither has its fellows agree to a restrictive covenant nor has elements of coercion in future job recruitments. The competing interests of profit vs. those of evidence-based practice need to be carefully considered and could be balanced through the development of a robust national fellowship curriculum wherein journal clubs and other didactics occur across all types of fellowship practice settings. Private practice investment in education and willingness to train the next generation would increase the overall number of graduating fellows and would expand the workforce. We should consider opportunities to change the landscape of private practice and private equity involvement in healthcare to focus not just on short-term investment but also long-term growth and include education and future workforce issues in these strategies (5Patrizio P. Albertini D.F. Gleicher N. Caplan A. The changing world of IVF: the pros and cons of new business models offering assisted reproductive technologies.J Assist Reprod Genet. 2022; 39: 305-313Crossref PubMed Scopus (11) Google Scholar). In addition, consideration should be given to reverting to a 2-year fellowship program with the opportunity to stay on for an additional 1 year of research-intensive or subspecialty-focused training in genetics or minimally invasive gynecologic surgery. Fellowships are currently accredited by the Accreditation Council for Graduate Medical Education, and the stringent requirements and lag time for the approval of new fellowship programs have driven the market to find alternative solutions. One example is the so-called "upskilling" of Ob/Gyn specialists, whereby these physicians attend a short training course and then perform IVF, including management of third-party reproduction cases. There is no doubt that Ob/Gyn specialists are highly skilled physicians and surgeons who can gain proficiency in performing egg retrieval or embryo transfer with targeted training. However, complex counseling and medical decision making, running an IVF and andrology laboratory, and strict adherence to Food and Drug Administration regulations for third-party reproduction require longitudinal experience and mentored practice for safety and quality assurance. The objectives of fellowship learning, as outlined by the Accreditation Council for Graduate Medical Education, delve deeply into clinical care in reproductive endocrinology, infertility, genetics, as well as principles and practice of research. Fellows must learn to identify these complications, manage sequelae, and follow patients through their treatment course. They gain invaluable experience managing more nuanced cases, such as medical fertility preservation, genetic and endocrine disorders, and difficult retrievals, because of body habitus or anatomic variances such as large uterine myomas or the absence of a uterus. In addition, learning about the research methodology aids in the interpretation of the literature, which shapes future clinical decision making. One cannot practice "evidence-based medicine" without understanding how the studies were conducted and data analyzed. Finally, board certification and maintenance of certification ensure that each physician meets minimum standards with regard to knowledge, judgment, and skills in the field of REI. The provision of assisted reproductive technology is a tremendous responsibility that requires not only extensive training and knowledge of the reproductive endocrine system and genetics but also a deep understanding of the ethical and psychologic implications of treatment. Bypassing fellowship training and board certification and using physicians who do not have the skills, knowledge, or expertise to practice the full scope of REI set a dangerous precedent. The question remains: how do we meet the demands of an ever-growing patient population? In the short term, REI specialists must find a way to improve practice efficiency to accommodate a greater volume of patients without compromising care. In the long term, the physician workforce should be expanded by increasing both the number of REI fellowship programs and the number of REI fellows trained in each program. As the workforce grows, there should also be an increased focus on expanding access to care beyond metropolitan areas. Our field is at a critical juncture, and we cannot afford to remain silent and allow the market to dictate our fate. The enforcement of and transparency regarding fellowship training and board certification are critical to prevent "upskilling." This level of quality assurance ensures that patients will be treated by physicians who are trained to practice evidence-based medicine that maximizes positive outcomes. It is up to us, physicians and leaders in this field, to control the narrative, define who we are, and enforce training that will provide patients with the safest and most ethical route to the most precious resource on earth, a family.