#019 - What Do We Grieve When Nobody Has Died?

Hello Friends 👋

In this episode, Rupa talks with Dr. Hailey Evans, a third-year fellow at Harvard's Neonatal-Perinatal Medicine Fellowship Program, transitioning to a neonatology faculty role at Yale. Hailey shares findings from her qualitative study of 41 neonatologists on death and non-death loss in the NICU — covering themes like emotional connection, weight of responsibility, and unsupportive workplace culture around debriefs and M&Ms. She also discusses the moral distress curriculum she built for fellows, why mentorship matters, and her advice for pursuing a research niche that feels too unconventional. A candid look at the emotional toll of neonatology, and how to carry it better.

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Short Bio: Hailey is a third-year fellow in the Harvard/Boston Children’s Hospital Neonatal-Perinatal medicine fellowship program. She completed her undergraduate degree at Barnard College and medical school at Tufts University. She completed her residency and chief residency at NYU, where she became interested in the impact of patient death and other difficult workplace events on physician wellbeing and resilience.

In fellowship, she has pursued qualitative research under mentorship of Dr. Richard

Goldstein, exploring neonatologists’ lived experiences of infant loss. Additionally, she

has created and implemented a novel, structured moral distress curriculum, along with

other support interventions, for NICU fellows under mentorship of Drs. Christy

Cummings and Kristie Leeman.

Hailey will be joining the neonatology faculty at Yale in a few weeks as an academic

clinician with goals of pursing leadership roles in medical education. She’d like to shift

her focus from exploratory work to intervention-minded research through a medical

education lens. Specifically, she’s interested in designing curricular interventions that

aim to improve trainee leadership skills during morally distressing cases, complex

communication, end of life care, and unexpected workplace events, as well as

developing trauma-informed methods for debriefing, case reviews, and morbidity and

mortality conferences.

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The transcript of today's episode can be found below 👇

Srirupa (00:00.856)Good morning, everyone. Welcome to another episode of Rupa's Fellows Friday. I have with me Dr. Hailey Evans from the Harvard Neonatal-Perinatal Medicine Fellowship Program. Hailey's a third-year fellow. She completed her undergrad degree from Barnard College and medical school from Tufts University. She completed her residency, followed by being a chief resident at NYU (New York University), and that's where she got interested in the impact of patient death and other difficult workplace events on physician well-being.

She's currently a third-year fellow transitioning into a neonatology faculty role at Yale, where her goals are to pursue leadership roles in medical education and incorporate all of her fantastic research that she did as a fellow. Hailey, welcome to this recording today.

Hailey Evans (00:46.82)Thank you so much for having me. It's an honor to be here and I'm so glad you invited me.

Srirupa (00:51.71)Awesome, awesome. And you've been doing some fantastic work, from what I see — a lot of qualitative research, is my understanding. And you work with some amazing mentors. And I'm interested to know all about your research today. Very interesting work. So share with us what you've done so far in your three years of fellowship.

Hailey Evans (01:13.372)Yeah, absolutely. So my main fellowship project is a qualitative interview study, and it's really focused on the neonatologist experience of both morbidity and mortality. We called that "death and non-death loss," just so we could use loss as an umbrella term to encompass both of these things, specifically in the NICU (Neonatal Intensive Care Unit). I interviewed 41 participants from all over Massachusetts — we recruited from all the different hospitals around our state. And I recruited in three groups: fellows, early-career neonatologists, and mid-to-late-career neonatologists. We used the standard AAP (American Academy of Pediatrics) Section on Neonatal-Perinatal Medicine definition for that. Our early-career neonatologists were those with less than or equal to seven years practicing, and mid-to-late career was above that.

I talked to them about what cases of loss have been most impactful for them, what that impact has looked like professionally and personally, and how they cope with loss. That was a really amazing experience, and right now we're moving toward manuscript development and publication, so I'm hopeful the work will be shared with a broader audience really soon. I'm happy to talk about some of the findings today. So that's the first thing I worked on during fellowship.

The second project is kind of both my QI (quality improvement) project and a medical education project — designing and implementing a curriculum, as well as some other support interventions, specifically about moral distress for NICU fellows. The curriculum is designed to not only equip fellows with strategies and tools to cope with their own moral distress, but also help them gain the skills they need to be effective leaders during morally distressing cases, because I think that's really a gap in formal education. With everything we're seeing in neonatology — the evolving limits of viability, increased interventions for children with

Hailey Evans (03:31.268)genetic disorders and congenital anomalies — I don't think moral distress is going away anytime soon. If anything, I think we'll continue to see it amplified. I think it's going to continue to be a huge part of our jobs, and so it was really important to me to help fellows learn how to lead their teams through situations like that.

Srirupa (03:54.796)Yeah, no, such an impactful topic, right? As fellows — and I can relate to it, not that I am a fellow anymore — I think that especially as a first-year fellow, you face such significant changes to what you experience as the frontline provider. I remember my first death, and I just couldn't process it. I wasn't sure how to best process it. And I think for most people,

Hailey Evans (04:18.354)Yeah.

Srirupa (04:24.258)there's like a first wave, and then a second wave hits about two weeks out. That was my experience too — yes, I felt very sorry for the family, I felt very sad, but then it came up two weeks later out of nowhere. It hit me out of nowhere: "Oh my god, this little baby that I took care of is no more." I think it's just variable how that experience is and how neonatologists in general experience it. And not just death — I think even

Srirupa (04:54.208)something as significant as a baby you took care of developing a spontaneous intestinal perforation (SIP), or NEC (necrotizing enterocolitis), or a baby failing extubation — all of those, we take personally because we care so much about our babies. Wonderful. So I'd love to know how you went about doing these projects, and I'd love to hear what you found out.

Hailey Evans (05:19.518)Yeah, definitely. So the first project was all Zoom interviews. I think the first step to approaching a qualitative study is to decide how you're going to collect your data and organize the structure in which you'll collect it. We did semi-structured interviews, so I had an

interview template that I generally followed and tried to hit all the points in the template. That template went through a million iterations — my mentors and I designed it, revised it, and tried to inform the content of the interview both by the available literature on all of these things and by

what we wanted to find out — our aims for the study. We piloted the interviews on non-study participants to make sure the language was translating the way we wanted, that people were understanding what we were asking. Then we revised the template further from there, and jumped in and did our interviews. I recruited everybody via email, and we recruited on a rolling basis. So

I sent many, many emails, and as people filtered in, I invited more and more. We did more targeted recruitment at the end, because I found I needed more fellows from my own career-stage group, so I specifically targeted recruitment toward fellows. The other group I wanted more of was people working in more

community NICUs — level ones and level twos — that may have fewer resources. I felt like those were really important stories to capture: what's it like to take care of a baby born in the middle of the night that you don't have the resources to care for and need to transfer? I wanted to make sure I captured those stories too. So we did some targeted recruitment at the end, and stopped recruiting once we reached thematic saturation.

We were keeping track of what themes were arising with each interview by taking field notes and reviewing them, and once we got to a place where we were hearing the same things over and over, and had an idea of what our themes were going to be, we stopped. And what did our thematic analysis reveal in terms of impactful cases? I think it was really interesting, because we talked about death and non-death loss

separately in the interviews — the first section was about cases of death, and the second was about cases of non-death loss. But in terms of the cases that came up, the themes were the same between both patients who died and patients who experienced serious morbidity. The first overarching theme was emotional connection to the case. This often looked

like a close relationship with the family, a close relationship with the patient — especially if the participant was a parent themselves with a child a similar age to the baby. That came up a lot. Or just an emotional connection to the content of the case itself. Twins came up a lot in this too, especially if one twin passed away, and the discomfort that comes with that —

cases where the family had been through a lot of losses, or had used IVF (in vitro fertilization) or other assisted reproductive technology and had a difficult journey to becoming pregnant, and then lost their baby or had their baby experience a serious morbidity. That came up a lot. So that first theme was emotional connection. The second theme was weight of role and responsibility — cases where the participant felt like something went wrong, something was missed, maybe the patient could have been saved,

and they felt some degree of responsibility. A lot of people thought about deaths that were "firsts" — like you mentioned earlier, your first death stays with you. There's this grappling with, "What is my role in this case?" when that first happens to you. That came up especially in our early-career group, who recalled their first death as an attending.

what it's like to be in that position where you're the one ultimately responsible for the patient, because you've never truly experienced that before. That was the second theme. The third theme was unexpected turns or challenges — patients with NEC and SIP, like you mentioned, patients who had been doing well and then experienced a complication, patients who suddenly had a code event either in the unit or in the

delivery room that you didn't expect, cases where there wasn't closure because no one really understood what happened and maybe there was no autopsy, or the autopsy wasn't conclusive. So that was the third overarching theme. And then in terms of

how loss cumulatively impacts you over time, as you experience it over and over again — the first theme there was that feeling of moral distress you personally feel, and the perspective shifts you go through about morally distressing cases as you experience more of them over time. The second was how outlook on patient survival and outcomes comes into play.

And the third was how experiencing loss impacts your professional fulfillment and well-being. There are certainly threats to well-being in our job — feelings of anxiety, responsibility, guilt, sadness, which are all so normal to feel — but there are also a lot of really positive impacts on professional fulfillment that our job can bring. We heard about those as well.

In the very last part of the interview, we talked about coping — how do you cope with these things, how do you process them, what are the barriers to coping? This is unsurprising based on the existing literature, but we heard a lot about peer support and talking to colleagues, and how helpful that can be. We heard about separation from work, self-care strategies, which are all excellent. And then we also heard about

barriers to coping. When I asked about them, people commonly cited other work-related responsibilities, or feeling exhausted, and how that can get in the way of coping. And about a third of participants — not the majority, but about a third — brought up a theme of unsupportive workplace culture. This most commonly came up either in a more formal setting, like a blaming or punitive nature to things like debriefs, M&Ms (Morbidity and Mortality conferences), and case reviews,

or in a less formal setting, like the gossip and talk that can occur on a unit, especially after a case that's more sudden and maybe controversial. I think that was actually the most actionable result I got — I think we have to do more work in terms of how we approach debriefs, case reviews, and M&Ms in a psychologically safe and trauma-informed way.

So that's the summary of results from the first project. Sorry, I talked for so long.

Srirupa (13:02.894)Oh no, no, you're good. I was just listening to all of these themes, and I can relate to every one of the things you said. Anytime that happens, I'm thinking, why aren't we talking about the emotional aspect for the physician here? We're talking about the medicine, we're talking about so many aspects of what could have, should have —

Hailey Evans (13:20.082)Yeah.

Srirupa (13:25.998)possible hypotheses, all of those things — but I feel like, yes, debriefs happen, but they should also address the emotional side of the event that led to significant mortality or morbidity, and we ultimately just talk about the science, the physiology, the pathology behind the autopsy specimens, and move on with our lives. So I think that's such an important opportunity. And yes, workplace gossip is such a modifiable risk factor — you weren't there, you weren't in the shoes of the person running the code, for anyone to arrive at a conclusion about what could have, should have, would have been done. I totally relate to all of that, because every workplace has these risk factors, and I think this contributes indirectly and directly to physician burnout and provider burnout in a lot of ways. No, this is wonderful and so impactful. Tell me how this turned into a curriculum, because I know that was part two of your project. That's so important for fellows to learn — one, to recognize when they're going through these moral distress situations, and then also

Srirupa (14:54.808)to take that lead role when it happens, or to recognize it happening with or to someone else. So share your curriculum-building process, because that's so impactful for a lot of fellowship programs that may not have a formal curriculum for it.

Hailey Evans (15:09.01)Yeah, I was so inspired. My fellowship research project — the qualitative interviews — was happening before I developed the curriculum. I was doing these interviews around the theme of morally distressing cases, but not just feeling your own moral distress — also the distress that comes from the unit as a whole, all the

discussions with nurses and trainees about "what are we doing, what are the goals with this patient, I'm uncomfortable," and how you navigate that as a team leader — especially because we know, and this was supported in my study, that physicians tend to feel less moral distress over time. I found that

people talked about these perspective shifts. Not only do physicians seem to become more accepting of parental values that may differ from their own over time, but they also seem to have a different perspective on futility. Many people talked about how there are cases on the unit that are, medically speaking, futile — the patient isn't going to survive, and we're

keeping the pressors on, keeping the ventilator on, whatever it may be — but it actually does have a purpose: to give the family more time with their baby. I think physicians tend to see that and have that perspective shift over time. So I was really inspired by what I was hearing, and by my own personal experience. I

didn't even hear the term "moral distress" until fellowship — maybe at the very end of residency — but I had no idea what it was. I was feeling it all the time and didn't have the words to describe it. So I thought it was so important that we teach, especially people going into intensive care, what moral distress is — that it's normal and okay. You're supposed to feel it. Our jobs are

Hailey Evans (17:20.306)ethically challenging sometimes, and it's not wrong or bad to feel moral distress — it's actually probably a good thing sometimes, since it's reflective of how much we care. So I wanted to make sure fellows knew what moral distress was, knew it was okay to feel it, and had a safe space to talk about that distress — but also that they were shifting into a leadership role and knew how to manage it.

So the curriculum started with two sessions I knew I wanted to do: an intro session on the foundations of moral distress, and a session where we did role play and introduced a framework for leading a team through moral distress — how do you guide your team members through this, respond to their concerns,

and maybe even help shift their perspective, while doing all of that in a psychologically safe and mindful way. I knew I wanted to do those two things, but because it was a QI project, we also did a needs-assessment survey and lots of interval surveys along the way, collecting data both on how

fellows were feeling about their knowledge and comfort with moral distress, and on the "temperature" of their own moral distress throughout the year, along with qualitative data about what they wanted to see in the curriculum. I really tailored the curriculum to what fellows were requesting. So in addition to those two sessions,

we did a specific debrief on patients with trisomy 13 and 18, inspired by patients the fellows had been caring for and wanted to talk about. We discussed the new AAP guidelines, did some debriefing about patients, and worked on strategies to cope with moral distress and move forward in those cases. We also did a session about

Hailey Evans (19:37.936)feeling distress in the current political climate. Everywhere we're seeing a lot of vaccine hesitancy, vitamin K refusals — and I think there's a lot of advocacy physicians can do in those situations, but it's also really important to find ways to maintain your own well-being and resilience, and know when to step away. So we talked about specific language and strategies for those situations, but also

ways to know when it's time to leave the situation and take care of yourself. The last sessions we did focused on powerlessness and conflict and power dynamics. I worked with the Ombuds office at Boston Children's to develop a session specifically about

how to approach conflict — the different conflict styles and modes we can use, which may be best applied in different situations. We talked about that, because I do think conflict is both a product of morally distressing cases — there's a lot of conflict between team members, between parents,

between parents and the team during these cases — and I also think conflict can generate more distress, because it takes away patient care time from other patients, and can make you feel more uncertain about the best path forward. So we did a session on conflict as well. We collected all this data over time, and the curriculum improved

fellows' knowledge about moral distress and their comfort with moral distress, based on scales we developed for the project. It didn't improve actual levels of moral distress in the fellows, but I actually think that's okay. We went in with the goal of reducing moral distress, but this work has really changed how I think about it. I don't think of it as this bad thing we need to

Hailey Evans (21:48.818)make go away anymore. I think of it as such an important part of the job, and we just need to make sure we're equipped with the tools to cope with it, process it, and help our teams do the same.

Srirupa (22:00.974)Absolutely. And I think, like you said, the first step is just normalizing that it's okay and normal to feel that distress. Such impactful statements, and very impactful work, Hailey. Going back to your first project — did you see any variability in themes between fellows and early-career neonatologists? That's part one of the

Hailey Evans (22:06.749)Mm-hmm.

Hailey Evans (22:17.064)Mm-hmm.

Hailey Evans (22:24.702)Yeah.

Srirupa (22:27.47)question. And part two: we do have a lot of international medical graduates — myself included — and I think death can be viewed differently because of different practices and cultural variations. Did you see any differences there — racial disparities, ethnic disparities? Just curious about those aspects of diversity as well.

Hailey Evans (22:33.96)Mm-hmm.

Hailey Evans (22:38.334)Hmm.

Hailey Evans (22:55.732)Yeah, no, those are really good questions. In terms of career-group differences, honestly, we didn't see a lot of huge differences — it was more similar than I anticipated. The few differences we did see: first, fellows

and early-career neonatologists who had children were more likely to experience that feeling of identification I mentioned earlier — both with the parents, because they're at a similar age and life stage, and with the patient themselves if they had a baby or young child at home, or were currently family planning or pregnant. That came up a lot. Early-career neonatologists were

most likely to recall that "first death" as an attending. That was another difference we saw. The last difference by career stage was this interesting, bimodally distributed view on patient survival and outcomes. Being pessimistic about survival and outcomes was still uncommon — less common than optimism — for all our groups, but both fellows and, actually, mid-to-late-career neonatologists were more likely to be pessimistic than early-career neonatologists. I don't have

Srirupa (24:23.054)[interjection]

Hailey Evans (24:39.604)a great explanation for why — I think we'd need to study it more — but I've thought about it a lot, and I think maybe in fellows it's more reflective of burnout and exhaustion, and in

mid-to-late-career neonatologists, maybe it's more reflective of some of the generational changes that have occurred in medicine itself — shifting away from paternalism and toward family-centered care. Mid-to-late-career neonatologists have seen so much change during their careers. Viability has changed so much.

The interventions we're providing to patients with certain genetic disorders, congenital heart disease, and other congenital anomalies have changed so much. I think it's probably easy to be clouded by the really difficult survival and outcomes statistics they saw earlier in their career — they may just be hesitant to believe things might be more positive now than before.

Srirupa (25:30.446)Do you think fellows are probably reflecting the opinions and thoughts of their mid- and late-career neonatologists? We do look up to a lot of mid- and late-career people — most of our mentors, for example. I feel like we relate to and get inspired by a lot of what mid- and late-career neonatologists say, tell us, or share with us.

Hailey Evans (25:43.154)Yeah, yeah.

Srirupa (25:58.829)Do you think we're skewed by that opinion in a way?

Hailey Evans (26:01.332)That's a really good question. I don't know — maybe.

Srirupa (26:03.47)Maybe, because we're training, and we just look up and have those same similar thoughts, I suppose. Very, very interesting. I'd love to highlight your mentorship experience — could you share that with me? As fellows, when we transition into a new facility, a new program, we tend to

Hailey Evans (26:09.128)Yeah, yeah.

Hailey Evans (26:18.278)Yeah.

Srirupa (26:30.734)I view it as almost speed dating, right — you're trying to figure out who best fits into your life goals and objectives, your research methodology, and so on. So along with talking about your mentorship, share with us one big piece of advice you'd give to fellows interested in your line of research.

Hailey Evans (26:34.249)I'm—

Hailey Evans (26:51.698)Yeah, I mean, I'm incredibly lucky as a fellow in the Harvard system, just because we have amazing access to mentors and resources. My mentor, Rick Goldstein, isn't a neonatologist, but he's really an expert on grief, mostly approached from the parental perspective. He's done a lot of incredible qualitative research.

He had actually worked with another NICU fellow a year above me, Kelly McCullough, who interviewed parents who had lost a child either from stillbirth or in the NICU, about their grief reactions and experience. I knew about Rick from Kelly, and also from my program director — I knew Kelly had had a really good experience.

I came into fellowship with a very specific idea of what I wanted to study, and I knew I didn't want to just jump on someone else's project — I wanted to pursue this specific idea. At the same time, I had absolutely no idea what I was doing methodologically — I'd never done qualitative research before. So I needed someone with that experience and insight. I met with a lot of people, and I knew from the beginning that

Rick really valued my ideas and my independence. He was the perfect person to guide me through the process — he knew how to create a semi-structured interview template, coached me through doing the interviews myself, and is obviously really skilled at thematic analysis as well. It was so valuable to have someone with that level of experience and insight who was also willing to let me run with this idea and area of interest.

So he was the perfect person to help me do that. And then my mentors for my QI project are my program directors, Kristen Leeman and Kristen Cummings. They were also excellent —

Hailey Evans (28:55.496)supportive of my idea, saying "this is so cool, you should do it," supporting my independence while being incredibly supportive, and helping support my adjacent interest in medical education. In terms of advice, I'd say, first and foremost: don't shy away from your interests. It took me a while to really accept that I had this interest in

physician well-being and professional grief and moral distress, especially as a trainee. I don't know if "ashamed" is the right word, but I was worried people wouldn't understand it or think it was important. A few people along the way — not many, but a few — warned me that this interest is very unique and niche, and that I should be careful about putting myself in a box, since there might be programs or positions that don't have the ability or desire to support that

niche. I tend to be the kind of person who hangs on to one critical voice over all the positive ones. Especially when applying for fellowship or jobs, that critical voice was in my head, and I worried about fitting into the mold of what fellowship programs and faculty positions were looking for. But I'd say that for every one person who's

been critical of my work, or doesn't understand it, or doesn't think it's important, there are ten or more who think it's amazing, are enthusiastic about it, and think it's worthwhile. It's cliché advice, but just be yourself — you don't want to work somewhere that doesn't value you and your interests anyway. Being proud and open and honest about what I'm interested in has been really valuable to me.

And I'd also say: don't be afraid to look outside the NICU for mentors and collaborators. That's been really important to me, and has expanded my view of all of these things I do.

Srirupa (31:04.234)Absolutely. I second that — never give up on your interests, even if it takes a while to figure out what they truly are. First-year fellowship is so chaotic — you finish up your peds boards, and even once you're done with that, you're still struggling to understand your place and position, learning all these procedures. It's a steep learning curve, but at the same time,

Hailey Evans (31:10.558)Mm-hmm.

Hailey Evans (31:15.132)Yeah.

Srirupa (31:33.09)finding your niche and your interest is also part of that learning curve. Wonderful, Hailey. This was a fantastic episode, and I hope everyone listening feels how impactful and important this area of research is. And they can get in touch with you if they have any questions.

Hailey Evans (31:54.118)Of course, please do. I'll probably use my personal email since I'm transitioning, but I can give you that too, and you can put it in the show notes.

Srirupa (32:05.708)Perfect, wonderful. Thank you so much for joining us, Hailey. Good luck with everything.

Hailey Evans (32:10.298)It was an honor. Thank you so much for having me.