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#040 - 👨🏻‍⚕️ Dr. Waldemar Carlo MD

Wally Carlo on the incubator podcast

Hello friends!

Daphna and I are starting a new series of podcast entitle "Giants of Neonatology" where we interview some of the pioneers of our field. We have the pleasure of kicking this series off wit Dr. Wally Carlo who in a short hour imparted on us so much knowledge, wisdom and experience. We are confident you'll thoroughly enjoy this episode. Thank you for your support. - Ben

Short Bio: Dr Wally Carlo is the division chair of neonatology at the University of Alabama in Birmingham. He completed his training in pediatrics at the University Children’s Hospital in Puerto Rico and his neonatal fellowship at Rainbow Babies Children Hospital in Cleveland Ohio. Dr. Carlo has played pivotal roles in the development and the growth of the neonatal research network. He was the lead author of the SUPPORT trial published in the New England Journal of Medicine in 2010. He has conducted numerous NIH funded randomized trials. His dedication to research and the advancement of neonatal care have made him one of the most published neonatologist of all time, and his work has accrued over 50,000 citations. He was the chair of the Fetus and Newborn Committee, he has been a major contributor to the success of the Neonatal Resuscitation Program. Dr. Carlo is beloved and respected educator and his work in neonatology has reached far and wide beyond the state of Alabama thanks to his talent in training future leaders in neonatology and to his contributions to textbooks and other projects.


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

Daphna 0:39


Ben 0:47

Hello, everybody, welcome back to the podcast Daphna. How are you today?

Daphna 0:51

I'm just so I'm a little star struck today. Really, that's a full disclosure.

Ben 0:58

It's a it's a big deal. Our guest today is is none other than Dr. Wily Carlo. And I want to get started because I want to start asking him questions. Dr. Walley Carlo is the division Chair of neonatology at the University of Alabama in Birmingham. He completed his pediatrics training at the University Children's Hospital in Puerto Rico and his NATO neonatal fellowship at Rainbow babies Children's Hospital in Cleveland, Ohio. Dr. Carlo has played a pivotal role in the development and the growth of the neonatal Research Network. He was the lead author of the support trial published in the New England Journal of Medicine in 2010. He has ducted numerous NIH funded, randomized trial is dedication to research and the advancement of neonatal care have made him one of the most published neonatologist of all time and his work has accrued over 50,000 citations. Last time I checked, he was the chair of the fetus and newborn committee. He's been a major contributor to the success of the neonatal resuscitation program. Dr. Carlo is beloved and respect and a respected educator and his work in neonatology has reached far and wide beyond the state of Alabama thanks to his talent and training future leaders in neonatology and to his contributions to textbooks and other projects. While he Thank you, thank you so much for being with us on the show today.

Wally Carlo 2:12

Thank you very much, Ben and Daphne. Thank you. It's a great pleasure to be here today to share ideas.

Ben 2:20

Awesome. I wanted to start off by asking you this question. I mean, you trained in pediatrics in the 1970s. And you were very successful, you were a cheap pediatric resident, and then you decide to pursue additional training. And you pick neonatology which, at that time was not the field it is today. So as a as a as an accomplished pediatric resident graduating, why not just plain old pulmonology?

Wally Carlo 2:46

Yeah, that was an interesting choice, because there was not a lot of priority for babies at that time. The field of pediatric had advanced a lot in many other areas, but not in neonatology. So that was a big challenge. I thought from the beginning that there was a potential to improve survival and quality of life. And that would have an impact for many, many years. So I thought there were too many babies dying, then, in fact, as a resident, I was told, when going to extremely preterm baby birth, I was told maybe 5050 chance that maybe we will survive resuscitation. So that was a really interesting, and I thought there would be a great opportunity for better care starting at the time of birth.

Daphna 3:45

Can you just for our listeners, when you say at that time, it'd be extremely preterm birth, what was the gestational age at that time?

Wally Carlo 3:54

So generally, at that time, it was like less than 28 weeks, it was not very common that they would survive, in fact, have still today in who considers separately babies below 28 weeks, and they're not counted in most of the countries in the world, basically, below 28 weeks are not counted in their statistics of infant mortality or childhood mortality.

Ben 4:28

I wanted to ask you, because of what you're describing, as the insight of a young trainee in the landscape of the field is quite impressive. I think a lot of trainees these days work under the assumption that my field has been pretty much worked out and the potential for change and improvements are minimal. You didn't seem to think like that. You seem to see neonatology as a field with the tremendous potential and beyond that the ability that you thought I could make a difference How do we foster that attitude in in trainees, when they choose a field of specialty?

Wally Carlo 5:07

I agree, I think trainees should not accept the status quo, they should question. And they should take on important questions, get big goals, important questions and try to answer, don't be afraid of the challenges. There's a lot of areas of medicine that can still be improved substantially. And that's where I thought back in the 70s, when I did the training, I thought these babies have potential to survive.

Ben 5:45

And I think the fight is the same. I think, in neonatology, we've seen that all we've done over the years is lower that edge of viability. So I think the same, the same perspective is still very much modern today, where you say, well, at the time where you had to make a decision between different sub specialty was 28 weeks or less, but today, we are talking about these 22 weekers. And, and the care for really, the very, extremely low birth weight infants. I think this is something that you mentor that other people can take on.

Wally Carlo 6:17

Yes, and it's not just a dimension of gestational age or weight. Also the severity of the disease, you know, nowadays, we have such a great survival with major complex, congenital heart disease conditions. And so same thing in many areas of Pediatrics, I think there's a lot of opportunities in pediatrics and specifically in neonatology to improve care. One thing that I'm always reminded I always tried to force myself is to think, Am I missing a genetic condition? Because there's so many diseases that we don't know about much. So that's always something that is very intriguing, and then finding cures or treatments for those diseases.

Daphna 7:07

I'm struck as, as we're talking, when we when, for, for example, especially our trainees, our fellows who are coming up, when they are met with like, this is the way we've always done things, but neonatology has changed so much in such a short amount of time that it's never been, this is the way we've always done things because that that target has been moving. But I wonder what recommendations you might have for people who are meeting resistance, where they are about, you know, being an innovator.

Wally Carlo 7:42

Yeah, so I think it's important to question, as I mentioned before, question, what's been done, and then study the literature and see what's been done many times, we're not we're not be aware of what's been published. And then those questions that keep coming back to your mind, keep track of them, I have a whole yellow pad. Now, now with an electronic version of it also, in the notes, in my on my iPhone, to keep a list of ideas of projects that I want to do. Questions that I think are very important, and the questions keep coming up. It's, it's a constant, finding that when you're examining patient when you're taking care of patients, the questions keep coming up. So take advantage of that opportunity. And try to improve the care of our babies by looking into this questions, sharing ideas with other colleagues.

Daphna 8:55

Gosh, if we could, if we could get our hands on that list that you have here. Let your yellow your stinking Pattice of idea.

Ben 9:04

Scanning dog I was scanning Wally's background with all the papers to see where the pad was.

Wally Carlo 9:12

Yeah, I think I think it's something because sometimes many times I'm seeing patients I keep at least a paper list. hardcopy of the patients but on the back of it, I'm writing ideas of questions that I don't know that I need to answer. And I go back in the literature and study them and then nice if I don't find a good answer, and it's an important question, I want to consider doing research on it. So it's a constant, constant drive, and I I enjoyed I think our patients deserve it also. And our colleagues want

Ben 9:53

Yeah, I think I think this is the ultimate goal of Zen philosophy is to reach this level of being a Always a student. And and so I think the humility and what you're describing is, is amazing. And I'm hoping that we can all achieve that goal of constantly being inquisitive and asking questions. I wanted to ask you about the NIC HT neonatal Research Network, right? I mean, this, this this network that has been extremely successful and has become a worldwide reference. I mean, there are other networks around the globe. But I mean, the US neonatal Research Network has really become a reference. Can you tell us a little bit about what prompted the need to start this collaboration between the different centers in the in the right it started in the 80s, if I'm, if I'm not mistaken.

Wally Carlo 10:45

That's correct. And I actually have a slide of a quote by Sumner Jaffe, he was one of the higher up people at NI CHD. And they thought there was a really big need for well designed, large randomized control trials, that were not being done in neonatology that was a major drive together, we did some large observational studies that would inform trials and maybe even practice. So there was a big interest in the ad and the NIC SD, launched the neonatal Research Network, I was fortunate to be part of the first cycle, I was in Cleveland then. And we were part of this vicious cycle. And it was great, we all were learning so much from each other. And it's, it's a great it's a great opportunity to be in a group like that you have good minds. Eager people eager to learn. You have senior people, you have junior people, it's a really a good forum for ideas. And then it gets reflected in the design of the trials. And in the publications and the importance of the publications. Just briefly, you mentioned the support trial, I'll tell you something interesting. As part of the support trial, we had the the oxygen arm, and we did a prospective meta analysis. So we decided on the what's called individual participant prospective meta analysis. That was really, really interesting. So what happened it's back in the early 2000, we shared the protocol with investigators throughout the world for other groups the copy the protocol, we wanted them to copy okay. So, so, we encourage them to copy it. In fact, we gave them the algorithm for the masking of the intervention, we provided all the information and materials and they design for other similar trials. So that meta analysis of that is called a individual participant. So each data from each patient or enter a prospective meta analysis. This was one of the first individual participant perspective meta analysis ever design. It was the first one ever publish. So this is a big advancement that that level of evidence of that paper it's called the Neil prom, if the audience they want to check on it is by Lisa, ASCII, a SK, i e, and I'm one of the authors are many other authors. And eats is the highest level of evidence of any paper in medicine. Why do I say that it was confirmed as a group of librarians in medical schools in the US and they work together to identify papers or as answered questions that are important from the literature. So that group was given the request to look at other individual participant prospective meta analysis from randomized control trials. And they said this is the only one there are so many developed participant observational studies, but there are very few prospectively sign, and there's only one randomize also. So this is a great example, why what's the importance of this? The individual participant meta analysis confirmed the results published by the support trial eliminated the differences between trial. Now when you have slight differences, say whether once, one or two, some of the results pass the point zero value or point 05 Or not, you know, so when you look at the individual studies, you may have some heterogeneity. But when you look at the meta analysis like this, you can actually determine if there was heterogeneity, it was zero heterogeneity, meaning the trials are homogeneous, the results are vertical. Yeah, so this is a fantastic meta analysis results with zero heterogeneity. All the definitions, pre specified all the outcomes we specify. So, it's really good evidence.

Ben 16:15

Yeah, I mean, this is this is this is amazing. I am wondering if you can share with the audience I mean, for the first of all, for the people who are not familiar with the support trial, the time has come to go look it up. But obviously, this trial looked at the different target for oxygen saturation. And I'm a big fan of of medical history. And I think the history of ROP and neonatology is something that's fascinating and reading the book by by William Silverman and seeing the evolution of how the evidence really evolved over time to reach where we're able today to screen and manage most babies for ROP. I feel like the support trial was the final the final touch on this whole historical endeavor. So I think I think it's kind of amazing that we get to speak to you about it. But what is it like when you take on this project? In the early 2000s? I mean, was, was there a lot of disagreement regarding protocols regarding outcome measures? Can you share with us what it is like to be in your seat when you're you're piloting the support trials? Yes.

Wally Carlo 17:23

So there were different many different ideas, many different investigators have different ideas of how to do it. I am not saying that, that was the only design that should have could have been done. But it was a pretty good design base on all the evidence at the time, all the guidance from a organizations of what saturation targets were being used. So we basically use saturation targets of 85 to 95, which was almost everyone was recommended the time and then decided, okay, we'll we'll do one group, we get on the high side of that range, and the other one on the low side of that range. And it was a pragmatic design. That got everyone on board, because they said yes, that makes total sense. So I give a lot of credit to several people at the NIH and in the director Research Network that were instrumental in in coming up with the right protocol. So, so it was good. And then he was embraced by many, well known investigators worldwide. And they thought the intervention was the right one. And the design was the right one. So they all we shared the protocol with them on purpose. So they you if they wanted to join us in the effort, and they join and the respective countries put money into it. So it was funded in the UK, in Canada, in Australia and in New Zealand, by grants from their governments, from their research institutions, major grants to all the sites that led to the opportunity to do this major study. And one of the design issues was really interesting. It's the the factor of design that was use. And we in Madison Alinea, I told you, we don't hear a lot of factor of the size, but there was a really good reason to do a factor of design because if you're testing an intervention to ventilate You can also affect oxygenation. And, and the way also clinically, if you're trying to achieve oxygenation, you in Part use the ventilator. So so it was the obvious way to go. But this was very innovative because there have not been major trials of factorial designs in neonatology very few, non as big as this one. So this was a an interesting design. That took a lot of effort to the sign and the conducted. This was not the first effort. We have previously done the safe trial sav E, which was also factor all designed with a venti lottery strategy, and what the other arm boss steroids, and that was early steroids, the trial went really well from the regulatory design point of view. In fact, the intervention decrease more severe BPD substantially, even though the trial was stopped early. But that is thorough steroids, the early steroids lead to an increase in power perforation. So they study that arm had to be terminated. And they thought, okay, we can we can stop the whole study and do a subsequent study of ventilation. And that's that was the decision. So that's an important study also, that led to, to subsequently to the support trial. Go ahead. Definitely.

Daphna 21:42

Well, I'm, I'm sure Ben has has more questions about the trial details. But you know, this was a rebel, this revolutionize the way we manage babies, right. But what I'm really just in awe of is what a task this collaborative effort was. And we don't see that so often in research, you know, we have, you know, groups trying to beat other groups to write the end result, when so much can be achieved by people pooling their resources, pooling the brainpower and working together to make these really big strides.

Wally Carlo 22:20

Yeah, this takes years. Okay, so I started to work on this in the early 80s. Yeah. So in the early 80s, we were trying to give oxygen to the babies a bit more oxygen, a bit less oxygen, a bit higher co2, a bit of a lower co2 to see how they would control their breathing. So we became very interested in this issue of a word to let the co2 or war word to aim for a co2 word, what Ossian to aim, with a lot of research. One of the most interesting findings was that premature babies had a high threshold of up the threshold for co2 For so the co2 had to be very high for them to breathe. That was revealing, because what we found out that for the babies to use their diaphragm, they have to have a high co2. Most importantly, to use the accessory muscles, co2 have to be even much higher. So now we were facing an issue that maybe we're using so much ventilation on the babies, that they were being get on the ventilator, we were not allowing them to have a co2 high enough to stimulate their breathing. So that was a very, very, really observation from the late 80s, where we made that observation and realize that we could improve care by letting the co2 rise.

Ben 24:02

And so for the people who are listening along this factorial design of the support trial means that the two target saturations that you were testing, were testing in in separate instances when the patient was either on CPAP, or on another mode of ventilation. And so so that if there's any effect that these modes of ventilation could have, then they were tested at the same time, correct?

Wally Carlo 24:25

That's correct. And that's very important, because let's say if you're changing oxygen, the you also have to change co2 In some specific ways. Fair enough. So so those were important issues. At the end, we found that it was good that there was not any major interaction between the two. So we then had done two major trials that subsequently led to many guidelines all over the world. On on, on how to use the ventilator. their preference of CPAP, if possible, and how to when the baby's off the ventilator and also the oxygen targeting.

Ben 25:08

So then the paper comes out in 2010. And this comes out in New England talking about target saturation range aimed at neonatologist and your email address is on the first page of the paper. Can you walk us through what happens? Like the day the paper comes out? Like is this? Is this like one of these things in the movies where you get to the office and your secretary is like on the phone with 100 Different people who are trying to get a hold of you? And ask questions.

Wally Carlo 25:33

So these quite unexperienced first throughout the whole review process. Okay. So first, it's really interesting that you're asking this because first, I tell you what I'm writing the paper and the abstract to submit to be a yes. And they tell me it looks like the results did not differ. We don't have the whole data. But start writing the paper. So I start writing the paper as if there's no difference in outcomes. And only about late October, did we get the results so that I had to change the paper? How it was changed. And then from there on it? No, it was submitted to be as in December, as usual, but it was also submitted to ninja medicine back in December. And then they're cops. Not for a few months, there's going back and forth with the reviewers and the editors. And obviously, the editors, like the paper a lot and the reviewers because they could have said combined into one paper, but they wanted both papers. So we have back the papers in England or medicine. It's great to have back to back papers in New England Journal of Medicine like you know, like why, like, appreciate the problem is that from from there, the career is downhill. Because you can accomplish. It

Daphna 27:23

seems like you've kept use you managed to keep yourself pretty busy after that.

Wally Carlo 27:28

Yeah, yeah. It's a challenge and the you know, you you you develop a an eagerness and appetite for even bigger goals. And well,

Ben 27:43

what was the other paper you're referring to when you're saying those two back to back? Because obviously, one is the support trial, the target talks, the target range of oxygen saturation for preterm infants, and what was the other one? And the

Wally Carlo 27:53

other one is there is a CPAP versus intubation? Oh, fair enough. Yeah. Yeah. So the other and you know, we were worried they would say combine them, but they were quite different. So, so, so we, we probably said two papers, but I say something coincidental. Coincidental with that was that that same year, a paper that I had from the other network that I work with the NIH, the Global Network, also had its major paper published in New England Journal of Medicine. So now it's three papers, individual medicine and downhill from there, you know, it's like

Ben 28:36

the New York Yankees of neonatology. You

Wally Carlo 28:42

know, it's really look, it's teamwork. It's interacting with people is trying to think of the best ideas and the most important questions in the field. So then you were saying about what it was like? Okay, so with the publication of the paper, so it's all timed within this accepted nuclear medicine, we asked them Can you postpone the publication for May to coincide with the presentation at PHS. So by that time, then we had heard from bas when the presentation was like on a Sunday morning and so so when we present the papers at PHS, we announced also the podium that they were presenting the two papers in the support trial, and the papers have just been published. And people are checking their iPhone or their phones and finding the paper the full paper there. So it was interesting experience and, and a great opportunity to work together with so many people. In the in the support trial, I think it may be about 300 or saw more involved collaborators, let's say, the physicians and researchers in each group but also the top, many clinicians in each group. But, but even more when you think of all the people in the unit, working with the patients and following the protocol, in the, in the global network, we had to count these people, at least the major ones, and the global network paper, there's 5600 People that work on that paper, they were all like our IRB trained and so it's amazing. It's a, it's a group effort. It's something that we, as clinicians and neonatology is working together, we can accomplish big, big things.

Ben 31:02

On that point, specifically, you are a master of statistics. And you are very comfortable with looking at data manipulate not manipulating Oh, definitely not the word I want to use. But But juggling with with the numbers, finding the right tests to analyze the data, can you share with our audience, especially for young trainees, the importance of forcing yourself to learn statistics in order to have any future when it comes to research? Because there seems to be sometimes a belief that like, oh, you can outsource the stats to the statistician once you've done your your data collection, and I think you would be the perfect person to talk about that.

Wally Carlo 31:43

Yes, I, I think learning about statistics and studied design in general is very important. And I had the opportunity to take a class on statistics, during the fellowship in a theory that was very focused on clinical research. And it was a great experience. And subsequently, I kept those notes I kept studying. And at times, I made a big effort to learn more. So one time I was going to apply for the global network grant. And I thought, Okay, I need to really become better at this. So I went to the library, and read several books, or scan through several books, and found what I thought was the best book, it just happened to be about over 1000 pages. So I said, No, Brass is a lot. But I read the book back to back and took notes, and learned so much, it was amazing.

Ben 32:57

For the people who don't use libraries anymore, I know exactly the feeling where you find the title on the index card, and then you get to the bookshelf, and you see this massive volume waiting for you like, way bigger than I thought it was gonna be.

Wally Carlo 33:12

Exactly. In fact, it was so big, I had to order the book, because you know, you cannot take it from the library for so long, such a long period. So I had to buy the book, which was interesting, because I actually learned so much from the book and learn all the innovative designs. And so there was a short paragraph there, that's struck me because it says it talks about a design that I had never heard about. It's called the active baseline design. It was just like, an eye opener. And I and he said, This design is particularly good when you cannot do a randomized control trial of an intervention, for example, an educational intervention. So this was actually exactly what I was going to do. I was going to do an educational intervention of a training in neonatal resuscitation and essential newborn care in developing countries. I was training 3600 birth attendants in this and that was exact design. So we put in the paper that we use the active baseline design. I actually went searching PubMed and did not find a single publication. And the New England Journal of Medicine editors question that the sign I knew they were going to question it because they had their right about it. So I sent them the chapter of the work that is discussed. They didn't recognize the author of the book, but he is one of the most important authors he has written in about 10 books on clinical trial design. So I had I had to put him in contact with the editors of the New England Journal of Medicine, who then recognize that yes, this was a valid term to use in the paper.

Ben 35:34

What was it again,

Wally Carlo 35:36

it's called active baseline design. And the difference in active baseline design to that unique things, the unique things about active baseline design, is that, let's say you're trying to introduce an intervention. You have to first do all the procedures that will ever be done in the in the whole trial, except the intervention itself. So you have to collect the data. Make sure you have a good baseline, and that's the term active, active baseline. So it cannot be that you start collecting data and things keep changing. No, no, they have to be stable. So actually, we collected data initially, which was really interesting. Because the bigger story short, we show that we could reduce stillbirth by 95% still fresh stillbirth by 95% in low income countries, huge reduction in a multicenter study. But where the active baseline comes in, is that it was a changing landscape of initially doing very poor facilitation, to the point that they were doing fairly Okay, recitation. So we had to drop out the other one because the basin was changing. So once the baseline stabilize, that meant they knew the basics, now we're going to tell the intervention. So that was a that was really, really an eye opener for me. And it's such a great experience. And then to subsequently see a paper on publish on the lay press in sambia, that infant mortality has been decreased by 50% in the country. Actually, they said they didn't know why, but I do. Teach in neonatal resuscitation, and essential newborn care.

Daphna 37:55

Amazing. I'm so intrigued that your your, your research interests and your academic pursuits have been so varied you you've been involved in almost everything you can think of that relates to neonatology. I wonder when you started out again, as a trainee, what was your intended path? You know, what, what did you think you would be interested in?

Wally Carlo 38:22

That's a good question. And I've thought about this so much, not just for me, but for so many other people. Because when you go to medical use, and you decide to go to medical school, or you're thinking about going to medical school, you might be thinking about your own decision, maybe arbitration, what he did. So you have slightly different perspective of what the career may be, ultimately. But so I were thinking, Okay, I'll be a clinician and pediatrician and I'll go back to my hometown and take care of the kids of my friends, you know, that was my plan in life. And then, you know, you start asking questions, and you realize, oh, there's so much that is not known. Now, so do I go and open a practice or do I go and learn more about this? And I remember when, when I was accepted to the fellowship, ay, ay, ay ay us. When I first joined when I went in the first week, I asked Dr. fanaroff. I asked him, you know, how am I going to be measure if I'm successful or not as a fellow? I didn't know much about how they would do the evaluations. I remember as a resident its monthly evaluations. But as a fellow Many of the month worth of research. So that was a bit of a different evaluation. So then he said, Well, you have to excel in both your clinical work and in your research. So suddenly, I was thinking, Oh, my God, I, I mean, I know I can be a good clinician, but I don't know that I can be a good researcher. So I asked Dr. fanaroff. Well, if I do a really good job as a clinician, but you know, not so not such a good job, SF, researcher, will I graduate from the program? And he was interesting what he said. Yes, as long as you try hard enough. Wow, that was really amazing. That was really interesting, because it seems so scary. To the challenge is to be successful. But trying hard enough, was not so scary. That that I could do.

Ben 41:00

That's, that's amazing. I since we're since we are talking about this, I wanted to talk to you about your leadership style, and how many people you've seen. Come enter and leave your your your division that you've trained, that you've mentored. What is your what is your vision of what a good leader is, especially in the field of medicine, where it's so stressful? There's so much pressure? In your I don't want to ask too much of a pointed question, because I want to give you as much freedom as possible.

Wally Carlo 41:33

Yeah, so So I think, you know, in medicine, we're all similar. In a way, let's say we all train in neonatology. So the fact that I've been selected as a leader doesn't mean that I'm the boss in every domain, it means more, that I'm the servant of the group, I'm going to help each one. Now my priority is no longer Me, My priority is them. So I'm trying to mentor them to support them. And in general, I have a slightly different philosophy of other people. But in general, I think of three major things that I want for each person in my group. So number riding, dimension or overriding way of thinking, and the first thing I want them to be happy to do well be healthy. In general, that's my main goal. That's not my number one. and my Number two is that they take care of their family and loved ones. And it's only the third one. And in that order, taking care of the patients that, you know, that completes the, what I consider most important, so. So in every interaction, we prioritize that we try to make sure that each person fulfills their life. And someone told me one time when people die, they'd rarely say, in the obituary, you know, I don't know he was, he was a good teacher a good flip. They talk a lot about, you know, what's a good father a good, good husband? A good yeah. So, so I think one has to put things in perspective, that does not mean that the work is not important. Yes, the work has to be done. He has to be excellent. So a relentless pursuit for excellence. Is is is is a driving force. For me. It's, it's try as much as I can to be the best person I can be. And when a more private group, I guess I'd say, a relentless pursuit for perfection, but I know that's not going to be possible, you know, but to pursue it, yes. It's okay to achieve it now, but we can achieve good, important goals important. answer important questions, if we focus on them.

Daphna 44:55

No, I think that's so valuable and I really believe that at, you know, happy conditions do better work. And, and I'll just mention, you know, Dr. Tom's who will will be speaking you know, will will let close out the show is art mentor and I want you to know that he I mean he is practicing your your, your legend, really? So I want I just wanted you to hear that. But I, I wonder then how did you do it all? You know you were so busy. How did you navigate that? And still, obviously your family is important to you and your mentorship is important to you. So how were you able to juggle all of those things in such a, you know, rigorous career?

Wally Carlo 45:46

Yeah, I think with the support of people around you. So my wife understood my kids understood. And they knew they were very important, but they knew that sometimes I may not be there because I had to be taking care of a patient, but that did not minimize their importance and same thing at work. So it's, I think it takes a village, you know, it takes everyone to be supportive of each other to be more successful.

Ben 46:25

What does it take to, to take pride in the growth and success of somebody that you're mentoring? Right? I feel like off too often, unfortunately, you see, you see young providers that are really rising stars, but then somehow the establishment feels like they're part of the competition now. And so there's this there's this tension that builds up? How do you as a leader, allow them to continue to grow? And and even if at some times, it may mean that they will be bigger than the institution they're currently at? or something? I'm just again, and I'm not talking about any specific examples? I'm just giving a Yeah,

Wally Carlo 47:07

yeah, well, I believe in the tide rising all boats. So I think we all together can be the tide that elevate everyone. And people will excel in different ways. And you have to, to understand that. And I agree to that some people will excel in their laboratory with animal models. And they will be excellent. And that's good. And some people will excel in the clinical area or as educators, or as mentors, or ask quality improvement people. So there's a lot many dimensions of excellence. And I think one has to recognize. I always joke with people by telling them, You know, I am not going to get a major awards, but maybe one of my students, one of my mentees can get the Nobel Prize or something like that. So that's great.

Ben 48:09

So we're doing something on the podcast this week, that is unprecedented, which, which is that we have a fourth person on the show. Ronnie Thomas is with us. If you don't know about Dr. Tom's, check out episode two of the podcast, where we interview Rooney and Rooney is is the reason how we were able to get in touch with Dr. Carlo. And you've worked with you've worked with with Wally, for many, many years. And the governor said you've been singing his praises and, and be and you've been the embodiment of everything he's been describing today on the show. And so we wanted to give you the platform to ask him questions. And obviously you knowing Him better than us. Maybe more more meaningful questions if we haven't reached that point yet. But welcome to the show, Rooney. And welcome back to the show. Ron. Yeah, go ahead.

Rune 49:01

Excellent. Yeah, no, thank you so much, Ben. This has been wonderful listening to Wally again, and you know, I think I've told you both that I work with Wally since I arrived in the US in 2002. And an often I referred to Wally as kind of being a did almost he's an amazing mentor, but he's also almost a therapist. So it's, you know, stopping by Wallace office is door's always open. And he always sits right next to you when you talk to him. And I refer to those short visits, frequent, frequent short visits, often as little vitamin shots of new New Energy, just feeling feeling really good about what it is that we do in neonatology and then really refocusing on the pursuit of excellence and really, ultimately, never forgetting the goal of improving the care of babies. And that's, that's something that while he teaches over and over and over again, and and that's just fascinating, and Wally, of all the people you're mentored from all over the world, from fellows who lived in your garage, to people who do have a new car. You know, do you have any count of who are now chiefs of neonatology divisions around the world?

Wally Carlo 50:29

Yeah, we have over 15 Now that have a chief of divisions in different places or chairman of Pediatrics. So yeah, there's there's many, and the number will probably keep increasing. So it's, it's been great to see so many people flourish, you know, we had always tried to defy top people, and Ronnie was one of those. So and we have always tried to help people because say, not everyone, no, so much every time in their lives, but they're eager to learn and, and they can be stimulated and you can support them. And I think it's, it's part of life that you helped, you have been helped, and now you're helping others. So I think it's a great opportunity in academic medicine and in in practice, also, because you're mentoring the union doctors and helping them throughout. When one finishes the fellowship, one does not know so much. So one can keep learning from colleagues all their life, and yesterday was in the National Conference. Let me put it this way. I was older than most speakers, but that that someone asked me where are you here? Well, you could be teaching us and I said, I'm learning I'm always learning. And that's the article Rudy knows we all have here we're always learning eager, eager to learn from each other.

Ben 52:20

So be so intimidating if you're doing a presentation as a junior attending and Dr Walley calm

Wally Carlo 52:29

it will probably you know, the person who's given the presentation probably knows more than me a guy that most like most EGNOS more than me so, so I'm always eager to learn. Yeah.

Rune 52:44

Go ahead. And is that focus that is just so fascinating, I think so motivating also. And also the the aspect of, you know, reaching out to worldwide so while he has a, you know, he mentioned Zambia, but he's he's frequently traveling all over the world in Zambia is we actually have from UAV, a base in Zambia and a neonatologist there. I wonder, well, if you can just tell us a little bit about

Wally Carlo 53:11

Yes. So we have a full time team in Zambia. The total team is about 300 people. And they're funded by NIH grants. And they are in the field. Know where they are most of them are Zambians, but there's a few there are on the field also to to be learning on the spot there and trying to come up with ways to improve outcomes. And we're trying to do very innovative things trying to improve outcomes. I've been blessed to be able to work with collaborators in other countries. So, so many African countries, we just published a paper. I think we had about 30 or 40 countries represented in the study and that's how these to reduce retinopathy of prematurity so so I'm working eagerly with Africans in Africa neonatologist to improve care there,

Ben 54:22

I wanted to ask you something that while you're I know you're very dedicated to families and your patients and to their families. And I heard that this dedication even extends to the point that you officiated a wedding in the NICU. Is that Is that true?

Wally Carlo 54:38

That's right. Yes. I I was a with the family here for the for for the wedding. While they were still in the hospital sick

Ben 54:47

so so they so they got married inside the unit? Yes, that's right. Yeah. Oh my Lord. Oh, my Lord infection infection prevention must have been pulling their hair out.

Wally Carlo 55:00

That's true, that's true. But it was really good because the baby was quite sick. And, you know, they, they, they were they wanted to get married, but they didn't want to wait until the baby went home. So, so that was a really good experience and the nurses and the doctors all brought gifts for them. We enjoy.

Rune 55:25

That was a special time. And Ben, I think I've mentioned to you that I do have a list of advice from Wally that I have on my computer. And I just wanted to, you know, while you want to describe to me, when you meet a person, you kind of see that person and kind of a special light that you think of the effort that has been put into this person's life. I wonder, I think that's such a powerful message. I wonder if you could share that.

Wally Carlo 55:56

Yes, that's true. So I think that's a very important way of thinking that has influenced me a lot. So when I see a person, let's say, a young doctor, I also imagine all that went through from even before conception how the parents dream of having a baby. And then throughout the pregnancy, how the mother did everything possible, to get a good outcome of the pregnancy. And then throughout life, how the parents kept helping the person, and then the teachers and their friends, and the parents of their friends are there so many people will have influence us. So if you see a person, there's a lot of history behind that. And you're good to be just one of those people that can help this person continue in their path. So So I I think it's important to consider how where a person has been all the effort they have put in to get to the point where they are.

Ben 57:31

I, we're getting to the end of the of the hour, and I feel I wish there was another hour. But one of the things that when, when talking to people who have worked with you, Dr. Carlo, everybody mentions the word energy, like you have this well have on ending energy. And how many years Daphna? Have we been in practice, like six and

Daphna 57:55

I'm tired?

Ben 57:59

And so please share with

Daphna 58:00

us the secret to D asleep? I mean, how does it work?

Ben 58:04

How does it how do we get to that level of unending energy?

Wally Carlo 58:08

Yeah, so So I think we all have it inside. I think you set your goals high. And don't get frustrated when you cannot achieve all, but know that there are people out there that are willing to help you. And together, we can achieve major things. I think I think the world needs us. I think what weather would be think about what would be the world without you. It would be different because you have saved so many babies in your life. So if you were not there, would that baby have survived? So to me, I think when we need to think that there's a lot of opportunities, a lot of people willing to help each other and that we together can accomplish a lot.

Ben 59:16

That's powerful.

Daphna 59:19

I wanted to make sure that that Dr. Tom's didn't have have any any other questions on his

Ben 59:25

close out the show. Go ahead.

Rune 59:26

Yeah, no, I think this is wonderful. I just what was important for me was to capture both the clinical aspect, the research aspect and the personality aspect. And I know Wally you're your big family man. Wonderful, wonderful family, wonderful kids. Could you tell me some a short little story of an initiative that you you did with your kids, either while traveling or of focus to kind of you because you've always had so many family stories that are motivating.

Wally Carlo 1:00:03

Yes. So we have a very democratic family even when the kids were little, it was all by consensus. So when we want to buy a car, we will not agree of what to buy. So once my six year old says, We need to buy a Ferrari, so my response was, immediately, that's a great idea. Let's think about it.

Ben 1:00:37

I was gonna say, I couldn't get on board with that. When

Wally Carlo 1:00:41

we started to talk about pros and cons, and they would all you know, I, we, it was like a Socratic method, you know, so everyone bring it up their points of view, until one of them said, but the Ferrari cannot see it only two people. So then the question was, okay, the way to buy a car for only two people. So we finished buying the regular big family Gary's at that time. It was essential woman.

Ben 1:01:19

Yeah, this is not the I wouldn't define our health, my household as a democracy. I mean, it really borders on dictatorship with alternating dictators at the helm. Well, this Daphna, did you have any more questions?

Daphna 1:01:35

So I actually, I did have one question. I mean, I knew you had one more, I know. You could obviously collaborate with anybody that you want. And I wonder if there's somebody that you had envisioned, or wanted to collaborate, but you with, but you haven't had the opportunity yet, and maybe that's in medicine, outside of medicine.

Wally Carlo 1:02:00

It's interesting, but I've reached out to people that didn't know me, and I wanted to collaborate. And it was really interesting, very positive. Okay. In fact, this person who is extremely, she's very, very well known in the field, she's number one in the world. So I email her and and see if we could, I could share her with her the manuscript that I was working on, if we could collaborate. And what was interesting is that she called me back. And she, she liked the paper very much. And she said, No, she wanted to collaborate, but not become an author of the paper. But she wanted to give me some advice. And there was interesting, so how I reached out to someone that is so well known. And she was willing to collaborate, and did not want to take our credit away or credit away from the first author, I was not the first author. But she didn't want to take credit away, she thought the idea was fantastic. And it became an important publication by by an undergrad student, he was an undergrad student, very. So So I would say, you know, some people collaborate to a larger extent or a lesser extent, but that doesn't eliminate the option to have a some kind of interaction and by that person, just saying, This paper is really important. And you may want to include this area in the discussion, it made the paper better and reassure us that he was good work, that undergrad student is now a physician. So, so it was good, because it convinced her, she could do research and she could be a physician.

Ben 1:04:12

So you reached out to a college students for collaboration that might cause I assume that the person was well accomplished already.

Wally Carlo 1:04:21

Oh, no. Okay. So the student came to me and I said, Yes, I'll help you with this. We were working on this area. But, you know, I want to be reassured that I'm not leaving this junior person in to something wrong. So I wanted to check out with the world expert on this to make sure I was given the right advice and we're in the right track. So yeah, so so it was I will serve in like

Ben 1:04:52

a like an intermediary intermediary. Got it. Got it.

Daphna 1:04:56

But I think that's it's just an example of why you've been so successful. You You don't see limitations, right? You just see opportunity. And I think that's just I mean, just, that's,

Speaker 4 1:05:08

I learned a lot today. All I have to say about that I,

Daphna 1:05:12

I hope that I can just take that into practice each and every day.

Ben 1:05:18

wildly. Thank you so much for being on the show with us. This was an amazing hour. And you are where we're starting a series of podcasts, with, we're calling them the giants of neonatology. And you're, you're our first our first episode that's going to be released. So we're very excited about that. And thank you so much for taking the time and for sharing your your experience and your knowledge. And thank you to Rooney Tom's as well for for helping us making this interview happen. Thanks again, this was this was this was terrific.

Wally Carlo 1:05:51

Well, thank you, Daphna. Thank you, Ben. And thank you, Rooney. It's been a great opportunity to share ideas and also learn from you.

Daphna 1:06:02

It's been our pleasure, our honor. Thank you.

Ben 1:06:06

Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address, the queue You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikhil spelled Dr. NICU. And Daphna is at Dr. Duffner MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you

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