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#050 - Dr. Richard Polin MD


Richard Polin on the incubator podcast

Hello friends 👋


No journal club this week as, like many of you, we are prepping for the neonatology boards on March 29th. We are so happy to bring to you the second installment of our Giants of Neonatology series. This time we have the pleasure and the honor of interview the amazing Dr. Richard Polin. Dr. Polin is a one-of-a-kind educator and we were fortunate to pick his brain on education, mentorship, and clinical teaching. We hope you enjoy this episode! - Ben


 

Bio: Dr. Richard A. Polin is the William T. Speck Professor of Pediatrics at Columbia University, College of Physicians and Surgeons and is the immediate past Director of the Division of Neonatology at Morgan Stanley Children’s Hospital of New York-Presbyterian. From July, 1977 until January 1998, Dr. Polin was a faculty member in the Division of Neonatology at the Children’s Hospital of Philadelphia and Professor of Pediatrics at the University of Pennsylvania. In 1998, Dr. Polin returned to Morgan Stanley Children’s Hospital of NY- Presbyterian as the Director of Neonatology. In the spring of 2006 Dr. Polin received the National Neonatal Education Award from the AAP’s Section on Perinatal Pediatrics and in 2017 he was inducted into the “Legends Hall of Fame”. Dr. Polin is the 2021 recipient of the Apgar Award from the American Academy of Pediatrics.

Dr. Polin has published over 200 original papers, 20 books (including Fetal and Neonatal Physiology, Workbook in Practical Neonatology, Pediatric Secrets and Fetal and Neonatal Secrets,) and more than 200 abstracts. Dr. Polin is the Chair of the NICHD Neonatal Research Network executive steering committee, and he is the past chair of the Sub-board of Neonatal-Perinatal Medicine.


 



 

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


Daphna 0:00



Ben 0:46

Hello, everybody, welcome back to the podcast. It's Sunday Daphna. How you feeling? You know,


Daphna 0:55

I think as good as you can feel, I guess. It is what it is, we just do the best you can.


Ben 1:04

That's right. So let's, let's give people a bit of an update. We're technically according to the unofficial schedule of the incubator. We're technically due for a journal club today. But instead we are having the pleasure of having with us, Professor Richard POLIN. And he is our second guest from our series, the giants of neonatology. And we're very excited about having Dr. Polling on. But we are pushing off journal club by one week. Because our co host has bigger fish to fry than to read a paper for journal club.


Daphna 1:46

I think a lot of our listeners are will not be joining for journal club this week, even if we have. But But I think I think people are not going to miss this interview. Oh, it's a really good interview.


Ben 1:59

Oh, no, it's not like we're giving you secondary content, please. But I do have to say when I was getting close to the board, and I was spending all my time studying and you see these articles coming out, right? You're like shit, like, how,


Daphna 2:14

how am I going to catch up, I


Ben 2:15

have to write I have to put pin this somewhere so that once it's over, I go back and I read this paper. But so that's what that's exactly what we will do. We will let the boards pass and we will most likely have back to back weeks of journal club to catch up on some of the articles that we need to review. So yeah, we're very excited to have Dr. Pauline on anything else that we have to update the audience. On Daphna.


Daphna 2:42

I don't think so. Okay,


Ben 2:44

so Dr. Richard Polen is the William T. Spec Professor of Pediatrics at Columbia University College of Physicians and Surgeons and is the immediate past director of the Division of neonatology at Morgan Stanley Children's Hospital of New York Presbyterian from July 1977 until January 1998, Dr. pullin was a faculty member in the Division of neonatology at the Children's Hospital of Philadelphia, and Professor of Pediatrics at the University of Pennsylvania. In 1998. Dr. Polen returned to Morgan Stanley Children's Hospital of New York Presbyterian as the director of neonatology in the spring of 2006, Dr. pullin received the National neonatal Education Award from the AP section on perinatal pediatrics, and in 2017, he was inducted into the legends Hall of Fame. Dr. Pauline is the 2021 recipient of the Apgar Award from the American Academy of Pediatrics. He has published over 200 original papers, 20 books, and more than 200 abstracts. Dr. pullin is the chair of the NI CHD neonatal Research Network executive steering committee, and he is the past chair of the sub board of neonatal perinatal medicine. Dr. Richard pullin, thank you so much for being on the show with us today.


Richard Polin 4:00

I am delighted.


Ben 4:03

The first question we like to ask to our guests and especially the guests that are part of this series that we started called the giants of neonatology is that when you decided to pick the field of neonatology, the decision making process was very different than the one that we have to we had to go through considering how much had already been accomplished in the field when you're making that decision in the 70s. It's a very interesting one, and I'm wondering what motivated at the time your pursuit of a fellowship and training in neonatal intensive care?


Speaker 3 4:37

That's a great question, as I think back to the 1970s, basically 1972 When I made the decision to enter neonatology, there were two things, probably more that attracted me. One was a individual who I looked up to, who seemed to be charismatic and liked what he did and name was smart and taught me a lot and his name was John Driscoll. And a most people don't know nowadays, but he was a former chairman of pediatrics at Columbia and chief of neonatology. And the other thing was, I enjoy the obviously the intensity of caring for sick newborn babies. And the nice thing was even in the 1970s, most babies who were ill got better with supportive care. And that was a an attraction for me to enter neonatology.


Ben 5:37

Do you think that? Well, I guess one interesting follow up question to that is, do you believe that the opportunities that the field presented to you back in the 70s are still as prevalent as, as they were back then today, for the for the people who are transitioning from residency to fellowship?


Speaker 3 5:59

The answer is, absolutely, in fact, I think the opportunities are even greater now than they were back then we studied, or my research was on fairly elemental things in dealing with neonatal physiology. But I think the opportunities for more sophisticated research, or opportunities to care for sicker newborn infants, and obviously even more premature in newborn infants, is significantly greater in 2022, than it was back in 1977. So anybody entering the field should be excited about the things that can be done.


Daphna 6:41

I loved your comment about how much of our work is really supportive care. But certainly neonatology has is changing, right? And we're becoming more and more invasive. What do you think about that?


Speaker 3 6:57

So there, I always say there's the opportunity to become more and more invasive. But the best needing intensive care is often the simplest intensive care. So a phrase I've used are mature, I own this phrase, I know others who have used it, is don't just do something stay in there. So there's a zillion things you can do to care for newborn babies, different kinds of ventilation, antibiotics that we never even dreamed of cardiac drugs, but sometimes the best thing to do is take a step backward. Look at the baby and decide what is best. And often that's the simplest thing and not the most complex thing, but requires


Ben 7:41

a lot of discipline and poise options.


Daphna 7:44

Yeah.


Speaker 3 7:46

The younger you are, the more you want to use stuff. And I guess I was that way back when I was younger, too. But now, I say some of that stuff is just stuff and doesn't really make things better. And maybe it's better if we just look at the baby, decide what's best. And sometimes, the simplest course of action is best.


Daphna 8:11

I love that. Yeah.


Ben 8:16

In preparing for this podcast, I was reading a lot of different things you wrote and listen to a bunch of interviews you gave. And there was a sentence that you said, I forgot, I forgot where I listened to it. But it was interesting. And I wanted to ask you about it. You said that. Advancements in neonatal care have been revolutionary, but not revolutionary. And I'm wondering if you can talk a little bit more about that, because I want to hear what you didn't go too much into into that specific statements during the interview that I watched. But I wanted to ask you what your thoughts were on that specific statement.


Speaker 3 8:50

So if you focus on the care of a preterm baby, I think about things that have to be done everything from fluid and electrolyte therapy, to dealing with infectious disease and respiratory diseases, and immaturity and a wide variety of systems. The advancements that have occurred in neonatology have all been important advancements a relatively small advance, but he take a surfactant to factoring was a great advancement in the 80s and early 90s. It's really become part of our standard regimen for preterm babies. But it took years until the safety and efficacy as a fraction was demonstrated. In fact, now I'll say that there's a trend to stop using surfactant when we have opportunities to use something like non invasive ventilation, where the outcomes are even better. And the same is true for other aspects of healthcare. The observations are things that have improved our care have been small ones, you look at caffeine. Caffeine seems to be a great advancement, but it wasn't revolutionary. was evolutionary. And now we're struggling about when to use caffeine, do E's early? Do we use it late? Is it harmful to some babies what the right dosing is? So it's a neverending story. And I think that as I look at how I've changed my practice, it's been an evidence based person, I'll say don't run to I tried to look at the literature, rather than saying, Well look what somebody did. And this looks like it might be good for babies. If it might be good, that's probably not good enough. For me, I try to choose interventions, which are treatments which look like they're evidence based.


Ben 10:40

Do you still? Do you think that our field will continue to evolve in this direction of evolution rather than revolution? Or do you think that we are primed for a revolution of some sort, and I'm, at the top of my head, I'm thinking of the work, for example, being done at CHOP on the bio bags and, and these things that did definitely look revolutionary. But I'm wondering, from your perspective, what do you think, where are we going? In your opinion?


Speaker 3 11:07

So such as you asked that question, I thought it would chop, and I spent a lot of my career at CHOP, and I know the surgeon who does up work, it looks really interesting. I don't think in my lifetime, as a neonatologist, my practicing lifetime, I'll ever see that as a treatment option for very, for fetuses that are very preterm who need to get the weeks until they become viable. So will that be revolutionary? If it is going to take a lot of evolution, and changes in what they're doing to make it effective. In fact, yesterday, I received an email, and somebody was saying they want to join a team that will provide supportive care for the fetus in utero. And I have responded after Sam debating whether they should respond at all,


Ben 12:00

but Doris bucks over there, you can't wait to open.


Speaker 3 12:04

Yeah, I might, you know, we're already stretching the limits with the survival 22 weeks of stations. And before we start to say, Well, let's start to provide care for the fetus in some sort of birth, I think that there's a million steps which do need to occur. And that means that will be an evolution, by time it evolves, it'll be using that word evolutionary. And I don't see that as became becoming part of our mainstay of treatment. And just as there's still controversy about the very immature baby born at lower margins of viability, we can talk about what that is, but for me, it's, you know, 22 weeks is barely viable.


Daphna 12:51

What I what I like about that kind of concept, especially for car trainees who are just trying to pick a research project is everybody thinks that they have to do something revolutionary, or, you know, the work doesn't have value. But I think kind of what you're saying is that it's better to do something that may be small but rigorous, and that we can integrate into kind of our daily practice. Yeah,


Speaker 3 13:19

absolutely. A phrase that I haven't heard recently, but we stand upon the shoulders of giants. And there were giants that preceded me in neonatology and we can go over their names, if you like jury loosely and have have federoff And their whole host of others and made great observations. And our continued progress is we take those and and let them evolve, make small advancements in his particular area that improves upon what was started years and years ago. Again, it's the giants that preceded us, that allowed us to make further advancements.


Ben 13:59

And so what's great that you're mentioning this because you are. You're the immediate past director of the Division of neonatology at Morgan Stanley Children's Hospital in New York, at Columbia. And to me, your view on evidence follows in line very well with a former director, who was William Silverman and, and I, I mean, I have his book where's the evidence? And, and I can't help but feel that you are you're following in his footsteps so well, with your approach to evidence I'm wondering if if he was also an inspiration to us he SME for example.


Speaker 3 14:47

Clearly, inspiration should be an inspiration through on the NHS ologists I remember back in the 70s when I was a resident at political babies hospital back then, he came to the hospital All and gave two days of what two lectures more than an hour each on evidence based medicine. I said to myself, I didn't know him as a time. So this guy is extraordinary in his approach to gaining knowledge. So and then after I became the director at Babies hospital, I corresponded with him, I'm sure many people do. It's not just me, but he would cheat who say, Richard, what do you think about this idea? And he comes and writes something that was pretty profound, something I had not I had not heard of before, so he corresponded over the years. But something he said to me back in, or he said in the 70s, he said that Colombia should never have employees CPAP without a randomized clinical trial. And I totally agree with that. I mean, I think and it's been tested now, a number of randomized clinical trials, all of which shows that as a benefit in terms of small benefit many death or BPD. But he sort of, he's a Columbia person, but never forgave, I think Columbia for not taking a great observation. And that was supporting babies through non invasive ventilation, and testing it to say whether it's effective or not. I don't know whether I should say that but. But he's somebody he said to me one of his letters. He says that Virginia Apgar, an icon, world famous, everybody knows the Apgar score, he says was anti intellectual, but she never wanted to test things. In an evidence based fashion she made hours to what she did was incredible. I'm not minimizing it, but he felt that she wasn't she didn't approach what she did in evidence based fashion. Right.


Ben 16:51

It was I mean, that's that I think is his is his is his This is why he's so great is His always abiding by the evidence not being biased always only trusting science. And I think, to me, his book on ROP. Retro anto, five broke pleasure. The modern perspective was such a great example of when you are not being rigorous and you let oxygen free flow, how all the side effects or the the negative consequences and how much time it can take to get back on track to something that could prevent harm.


Speaker 3 17:28

It's a really interesting story that she tells a million, which she told me pretend better than me. But Wilson's observation that oxygen would decrease periodic breathing lead to the epidemic in the US so on controlled oxygen use in premature babies for the first month of life. And it took people from other countries from Australia and UK who are getting are incubators that could supply a lot of oxygen to premature babies and make the observation that oxygen was a major factor in causing retinopathy of prematurity.


Daphna 18:04

I think that fits with your clinical practice, though, that we sometimes we do things just so we feel like we're doing something right. So we're making a change. And in perhaps being more conservative, and really looking at the evidence, before we roll something out is definitely the safest thing to do.


Speaker 3 18:24

You're not rolling out learning from smart individuals. So if someone has spent a lifetime and it's not been studied, as a randomized trial, or a large observational trial, sometimes listening to smart individuals, makes sense to me. And sometimes around the fact I just got off service, I'll say, this is not an evidence based thing. But a buy in my practice, I found this useful. And I was talking about caffeine for babies on non invasive ventilation. We're very mature, this makes sense to me to do it this fashion and so there's still room for smart people and learning from smart people. And I don't want to give the impression that everything has to be evidence based.


Daphna 19:13

I do you think that's something that that plagues our trainees, though, when they say well, why, especially in neonatology, well, why do we do this? And then we have to say, well, it we don't have great evidence for it. But but it seems to be working well for babies at this point.


Speaker 3 19:30

Right. And if it seems relatively safe, I think it's the other thing someone recommends something and is a lot of risk for it, then I'm not sure you want to do it. But if it seems relatively safe, something like caffeine, which has side effects, but it's relatively safe, then it's okay to listen to a smart person say they've had a lot of experience. This makes sense to me. Maybe I'll study in a randomized clinical trial, but for right now, this is what I would recommend.


Ben 19:57

I think this goes to one of the quotes that William Silverman hasn't this book? Where's the evidence by John Tukey? Who was a mathematician who said, it's far better to have an approximate answer to the right question that is often vague than having the exact answer to the wrong question, which can always be looked to be made precise.


Speaker 3 20:15

You're that's a great quote. I don't remember that quote. But there are a lot of incorrect, precise answers, which, which lead us down paths that were just not fruitful?


Ben 20:27

Right. And that leads me to wanting to talk to you about about the state of neonatal evidence, I think, trying to close the chapter on William Silverman, because I don't want to talk about what you're selling and the whole interview, but he does make a case. Back at the time when he writes his book about we need more systematic reviews, we need more meta analyses, and, and trying to really get data from randomized trials together to get the best possible level of evidence. And I think since since he wrote these things, the Cochrane Library came into existence. And now we have a nice library of resources when it comes to meta analyses. But what we noticed these days is that many of the questions that the Cochrane Library is trying to answer specifically for neonates very often ends up with a statement that says, Oh, we do not have enough evidence to make a recommendation. And like we reviewed recently, this Cochrane review on the delayed initiation of feeds. Sometimes the evidence really spans a wide a wide time span, where it's like, oh, some studies from the 70s plus some study from to 2019. And so I'm wondering if you, if you feel like I'm wondering, what is your perspective on these on this on this shift in the medical evidence where these meta analyses have taken over as, as the top of the pyramid? Do you think we have to be cautious with them?


Speaker 3 21:48

So I gave a talk on balancing science and art, and where do we learn, I think is to put meta analyses at the top of the pyramid is totally incorrect. I put it down like three or four steps, the will design, large randomized clinical trial with sufficient power. So the question for me belongs at the top of the pyramid is a famous quote, for it was a New England Journal of Medicine back in the 1990s, the author was little Laurier. I mean, I've said his name correctly, to say something like this, if a subsequent randomized clinical trial had not been done, meta analyses would have led to an incorrect assumption about 30% of the time. And I think that meta analyses are useful. Very, Coyne is in the right direction, but they may not provide the truth. And sometimes they're dominated by one study, there'll be 15 studies in a meta analysis, and one is large, and 14 are small. And we're forced to accept the statistical result of showing one way or the other. The meta analyses are a guide. But for me, they don't dictate care. And I'm, I'm pretty careful with meta analyses.


Ben 23:16

Careful is the word. Okay.


Daphna 23:19

It seems like to your point that, you know, science in general is moving away from replication of the evidence, because everybody wants to be the next big thing, or they want to be the first group to, you know, evaluate whatever it is that they're evaluating. How do you think that has affected science?


Speaker 3 23:42

I think almost everything needs replication eventually, and more people to replicate, the more we've refined our use that we're fine. The observation that was originally made, and maybe it was incorrect. Or maybe it was partially correct. I have a lecture I'm putting together I'm giving overseas next week, and it's on PDA. And it's incredible. That when studies replicate earlier observations, that how good ligation PDA was now, rock climbing is outstanding, and it's sort of the father of PDAs. I worship everything he writes, basically. But his original observation that ligation, the PDA was beneficial, has since been disproven by 50. Other studies, most of the randomized sniper trials, which says ligation of the PDA gets you nowhere. And now I think my approach and what I tried to teach in the NICU is before you choose to medically or surgically close or your cardiac cath and as low as a PDA, you want to look and see what the evidence really says about that there's very little to be gained by closing a PDA so unless we He had done the subsequent studies who have just accepted an observation from the 1980s. At a time when antenatal steroids were not being used very much. And our car and our intensive care is very different to decide what to do. So I think that there's a need for replication and other studies to say, Is this really true? If it's not what it part is not true, and we need to refine? I


Ben 25:32

think this is such an important point that you're making. And I think you've written about this, but this to me, makes me think of our overuse of antibiotics in the NICU, where it was almost dogmatic that yes, you're admitted to the NICU, you had to be on antibiotics. And, and the I mean, I think we, I forgot, I don't have the name of the paper in the top my head, but we can share it on the on the website, where you're going over the different immediate side effects, long term side effects. And these are sometimes unintended consequences, because the motivations of the clinicians are good, they want to prevent something. How, how, I mean, how do we change the tide? On these dogmas that are sometimes established? I mean, I know you started answering that question by saying, having to question but it can be very hard, like, how do we overcome the I mean, if you're a young investigator, it's very daunting to say, Hey, I'm gonna I'm gonna question this thing that everybody is doing around so


Speaker 3 26:36

to most, first of all, I want to say, when I talk about antibiotic, I say, Mia culpa are mature, I am to blame. Because I was a person who recommended all kinds of antibiotics. So as part of the original CDC treatment guidelines, the I wrote the Academy of Pediatrics committee fees and newborn guidelines, precepts, and basically those were all wrong. And I'm willing to say that now because you weren't smart enough. And finally, someone started to ask the question, initial question is, does prolonged treat with antibiotics have a risk or benefit for newborn infants? I remember one of the studies by Mike cotton, Chief of neonatology adu and he showed us that prolonged use of antibiotics increases the risk of late onset sepsis increases the risk of necrotizing enterocolitis. And then following that, a host of studies show that even three or four days of antibiotics changes the microbiome of a newborn infant. And there's changes in microbiome, again, subsequent studies have been related to a lot of diseases which appear in childhood, or in adulthood like Allergy, Asthma, diabetes, obesity, just to name a few. So somebody had to say, is this the right thing? The various that some people have thought that Mike cotton had, he took a large database, and asked the question, sometimes important questions, don't start with a randomized trial, they start with an observational study. And then he's observational study led to other observational studies in the whole Microbiome Project, starting in the 1990s, allowed us to investigate small changes in flora that were associated with adverse outcomes in childhood.


Daphna 28:35

I love that you're able to be so you know, reflect and introspective on that. And to say, you know, we have new evidence, and that may be modifies some of the, you know, the recommendations we've been making. Why do you think it's hard for so many in in academia to say, like, well, maybe that was wrong, and that maybe we have to reevaluate that?


Speaker 3 29:01

Yeah. Well, that's a great question. It is. Human nature, nobody likes to say they're wrong. But sometimes you just have to own up and say, Listen, that sounded right at the time, based on the data that we had, that we had back in the day, I wrote some of those reports in the early part of this millennium and read 2010 or so. And based on new data, there's we're not the right thing to do. And we're and now the newest recommendations, which are not mine. From the 20 fees a newborn identifies groups of babies, you probably don't need antibiotics at the time of birth, and I think that's the right approach. However, however, we still don't know and is symptomatic baby, whether it's better to treat that baby with antibiotics, or, or not. And so, we have an ongoing NIH study That's gonna try and answer that question.


Daphna 30:03

Yeah, well, I think like, like you said, being a part of the discussion in the process helps helps with progress by not being able to say, well, maybe maybe there is a modification to make that, you know, might people be be standing in the way of progress. So So I appreciate your openness about


Speaker 3 30:22

one of my advantages, whether it's good or bad, I've been invited to give a lot of lectures over my career, and listening to smart people tell their story, to how they view the issues has been of great help to me in sort of transforming my own thoughts about what's good, what's bad, etc. So, I've been lucky to be able to listen to some really smart people. And that's affected how I practice and how and it's also affected, the research I've been involved in.


Ben 30:58

I want to Richard, I wanted to talk to you a little bit about your role as a clinical educator, because, again, in researching this podcast and preparing for this podcast, everybody I spoke to highlights how amazing and how great you are as a clinical educator. And I wanted to then ask you a very simple but maybe difficult question, what makes a great clinical educator?


Speaker 3 31:22

Yeah, it's a hard question. And it's simple, a simple part of that. Someone who really cares about education and training the future clinicians and academicians that will follow so caring about them. And then the steps involved are obser, such as, like research, you start with observation, they say, well, that person really gave a great lecture, or I really enjoyed rounding with that individual, what did they do, that I can incorporate into my own practice? So just like research or more rigorous topics, you can look at education, and learn from watching other people and then incorporating that into your own style, I'm sure. My educational style is what I've learned from a whole bunch of other individuals who, who did it well. And and then, what I tried to do, when I'm on serve as I just finished service, as I told you, is pass on those tricks of education to the fellows I'm working with. They're, they're the next generation in neonatology and say, Look, I say to you conduct rounds. Today, I'm gonna watch you conduct rounds, and they'll go and there'll be maybe the respiratory distress syndrome. And they'll ask the residents about rds and about surfactant and timing of surfactant and outcomes. And I say, well, you're really knowledgeable about that. But that's not how you teach people in formal setting. And one of my phrases is a for trainees is that trainees will remember three facts. But they'll never remember 300 facts. So when you are trying to teach somebody is it's too for lecture too, and you're trying to get points across, you got to be selective in what you want to teach, and teach those three things. And try to teach it in a fashion that remember one of my skill sets or skill sets. As always try to pair teaching about something with a little bit of history that might be fun. So pairing an important clinical fact with something that's totally irrelevant. Right. We all know the story of phototherapy and sister ward. So but the residents here that the first time and here's a story about phototherapy, and then you talk about phototherapy given the three facts, it's much more likely to do remember that as part of their knowledge base than if you tried to say everything about Billy Rubin and phototherapy, etc. So I tried to my approach to education is trying to be as simple as possible, try to pass on the skills to the next things that have helped you and your career. Well, I still I watch other people lecture and I say, what's good, what's bad about that? I've learned how to play the hard fashioned trying to conduct construct slides. I've had a lot of bad slides in my career. I tried to do this in a much clearer fashion. So you learn by watching and observing. I'm sure people do that randomized clinical trials. I'm not an educator. So I'll never be part of that. But there's a lot you could learn just from watching other individuals.


Ben 34:55

I need to Richard poling console then because what wakes you up What you just referred to right now, is that you say, Oh, you're going to give a few facts on rounds. But sometimes I feel like maybe like I'm early in my career. And yet I still feel sometimes, like, am I saying this for the 1500? Time again, on rounds? Are the nurses gonna say, Oh, this guy just keeps repeating the same thing, every time. And I am wondering, how do you deal with this? Because you're never sure if the person who are on the people who are nouns have heard you say those things? And then you're worried about did? Am I repeating? Am I saying the same thing again? And because you're the attending physician, nobody is going to tell you Hey, buddy, because he already learned


Speaker 3 35:34

you're exactly correct. So I always, as you know, resident teams during change during rotation. So I'll start with one resident team and teach them some facts, a new team will come in and I'll try and teach them similar information. I always preface and then they'll come back for another rotation. I preface and say I apologize if I said this to you in the past, but it's important. And here's, here's why it's important. And so here are the three things you want to remember about floating electrolyte therapy and babies or two things remember about treating hyperbilirubinemia? So I, I preface it with an apology. And I'm sure I repeat myself. I mean, sometimes I remember repeating myself.


Ben 36:19

Yeah, that's the worst. That's when you'd happens. And you're like, shoot, I did say that earlier this week.


Daphna 36:24

Earlier, this on the last baby, right


Speaker 3 36:26

was the last baby or the person before me on service, but it's been a similar thing. And they'll say, oh, yeah, Dr. so and so said, they'll say, Oh, great. I apologize. We'll move on from there. But we will I think repetition is part of the education process. And it's important. So if you repeat things, chances of them remembering your first go around are not very good. So repetition is good for all of us.


Ben 36:52

All right, I feel better. I feel better about myself.


Daphna 36:57

I think that could be a book, you know, three things you could your top three things about a whole host of topics. I would I would I would get


Ben 37:06

so my favorite. My favorite book. My favorite Richard pullin book is the fetal and secrets, right? I mean, you wrote many, many books. I'm not going to even attempt to list all the books you edited, written contributed to, but the secrets is somehow it's on my nightstand. Like it's always cool. Like you pull it up, then you get a few facts. How did that idea come about? I mean, the reason I'm saying this is I kind of feel like I know what you're gonna say. But you are you wrote textbooks, right? I mean, you wrote textbooks, and then how do you say I'm going to write a little handbook with some random facts about every organ system in neonatology.


Speaker 3 37:48

So here's, here's the story. It's true story. It started with pediatric secrets, not a neonatology textbook, which I


Ben 37:55

have, by the way, thank you for purchasing that.


Speaker 3 37:57

So I wrote a chapter for a pediatric publication. I forgot it was an AP publication on necrotizing enterocolitis. And we did that did that as case studies, and I read it, I wrote it with a non neonatologist. His name was Fred bird name, you'll never remember a very good educator died a number of years ago, quite suddenly. And after we did that, the editor of one of the editors from Elsevier was Elsevier was not it was called Saunders back then. That's right. But before even before that, there was a woman named Linda Bill office, who gradually or eventually became a senior member at Saunders invited me to do a whole book of case studies. And we included necrotizing or colitis. And we're now I think, thinking about our seventh edition of that. So that's called mega back. That's called the workbook and practical neonatology. Right. You may you may have seen, that's all case studies. In fact, my new co editor for that's going to be Tom Hayes view, you know,


Ben 39:17

actually, who actually I wanted to give a shout out to at the end of the show, but he's, he's responsible for making this interview happen. So Tom, thank you.


Speaker 3 39:24

So Tom's gonna be my co editor and secrets. Pediatric secrets, was a thought of Linda belfius, who also was our person for the workbook unprecedented neonatology, and my co editor who I still have his name is Mark Ditmar. He's a great general pediatrician. And we decided to do facts about a wide variety of things, but combining it with humor. So if you look at especially pediatric secrets has a lot of humor. In fact, it has cartoons. If you look at the cover, or the inside page for pediatric secrets has pictures of our latest addition our children and our grandchildren, we thought that would be fun to put into it as a cover to a book. So, again, since like I say, my teaching rounds, I try to combine useless facts with facts that are important about diseases. I think both secrets, pediatric secrets, and fetal Nia secrets use the same strategy of combining. I won't call it relevant, but interesting, irrelevant information with things that are important to learn about diseases. And most of our questions in the book are short. They're not long, it's not someone's gonna tell you everything about rds, we're gonna answer a simple question about is this better? Is that better? And give somebody's perspective. And pediatric secrets, I think is in its sixth edition now. And year two will be in a seventh edition.


Ben 40:55

Amazing. Yeah. Go ahead. Ben, did you have something? No, no, go ahead.


Daphna 41:00

No, I. You're quite humble about your skill set in being a clinical educator. And not only are you a clinical educator, but it's a totally different skill set to be a mentor, right for young, young physicians, young clinicians, and especially in the arena of research. And obviously, you valued the mentors that you had. And I wonder if you can talk a little bit about what you think it means to be a good mentor.


Unknown Speaker 41:32

So I've had good mentors and bad mentors.


Daphna 41:37

And that's how you learn I guess, yeah, when


Speaker 3 41:39

I was a fellow, I got struck with some really bad mentors who would come into the lab, these are laboratory mentors once a week is a, a rich, what are you doing? I try to sit down and tell them what I'm doing. And then come back a week later and say, rich, what are you doing? The good mentor for a research project? Is someone who you who you're seeing or what you're meeting with an individual at least three times per week, five days a week, not necessarily, but at least three times where we to find out? Where are the roadblocks, what are they doing? Are they making any progress are the results not what you would expect? I always tell people, what if you do an experiment, and the results are what you expect the first time you've probably done something wrong. And you want to repeat the experiment is likely to be incorrect. So it's it's taking an interest and and what the individual is doing and meeting with them on a regular basis and offering ways to help them move their research along and I did have mentors a lot of my career who were like that. I have had mentors in the laboratory. Good friend of mine Bill spec. They'll spec used to be the CEO of Presbyterian Hospital and chief of pediatrics at Case Western Reserve. When I was in his lab, he was there every day and we were talking about experiments we were we were going to do and I've had mentors in my career mentors. And people like names it may not be familiar to most people did Richard Biermann Richard Sherman is one of the editors have used to be when the editors of Nelson Nelson's textbook or pediatrics, Waldo Nelson was his father in law, like I said, helps have a father in law who, who is whose Nelson textbook of Pediatrics, but him and other mentors in my career. Dick Johnston, famous immunologist, one of my mentors when I was at the Children's Hospital of Philadelphia, Philadelphia. I didn't want to leave anybody else. On solchen


Ben 43:49

second Oscar winning speech him you can't forget someone.


Speaker 3 43:59

There, there are others in my career. And they're more career mentors. And I say, I have an optic, I'd write to somebody and say, Listen, I have an opportunity to do this now is good for my careers. It's bad for my career. What do you think and people come to me with the similar kinds of questions about I've been offered a job at X, Y or Z. Is this the right kind of opportunity for me? So I, I, sir, I try to serve that purpose visit with people in my life. who serves that purpose for me? So it's your career mentors. There are research mentors, there. There is mentoring I do in the NICU, as I already mentioned on a regular basis in terms of education.


Ben 44:49

I wanted to go back a little bit about the number of books that you've written and it's and it's interesting to me because for many influential physicians who have written books yourself I often associate them with a single series. But in your case, I've I find that this is quite difficult to pin you down to one specific book that this is the book you really devoted most of your time to. I think all the books that you've contributed to, or written or edited, are all amazing in their own rights. And I'm wondering, I mean, yeah, how do you pick so many different projects and make sure that they don't overcast? The other? You know, I think this is this is very interesting to me.


Speaker 3 45:29

They're all very different books, pediatric secrets, and fetal and neonatal secrets are short questions about a wide variety of topics workbook, compressing the hlG are all case studies. And individuals who read as his chapters go work through those case studies, the physiology book is totally dense. I've read I read every addition, almost completely. Now I have a bunch of CO editors who are just fantastic. And we split some of the editing editing opportunities. But it's it's I don't expect anybody to sit down and read that whole textbook from start to finish. It's just impossible. And they're all forms of education. The Secrets books are made for more for residents, I think. Also for fellows, but pediatric secrets clearly for pediatric residents. The workbook is very popular with nurses, and with our neonatology fellows, and the physiology book is meant to be a reference textbook and I do others. I have to say that every time I edit or learn, so people say is it as hard work? And I say, yes, it's when I do the physiology book, I basically work seven days a week, I read chapters, I take it with him on airplanes, I do editing when I'm traveling. But I learn from all of that, from all that work, because I don't write everything I hope you say me writing, I don't write everything. I've written a lot of chapters in my time. But I read and edit what really what I think are really smart people have written. And so I've learned it's been great for me, because I've learned and made myself a better clinician, and academician


Ben 47:23

it's almost going back to this mantra of it's more important to it's the message is not as important as the messenger, if you can be a great messenger, sometimes it's very powerful.


Speaker 3 47:33

I have to say, the educator, I've done a lot of research studies, and I'm still doing them. But education is probably the most important, the most satisfying part of my career. Passing on my information. I always say that when I teach somebody something, the greatest fun for me is to hear that person recite the exact same facts to somebody else. And that's what education is all about.


Ben 47:59

But how do you manage? I mean, honestly, speaking, today, you you're doing rounds, you're on service. And when all these projects collide, like how do you devote? How can you create a little vacuum around each project so that you could give them your full attention and not be distracted by your administrative duties, your clinical duties research, it's, I'm wondering if you have any tips or tricks for the few of us who are overwhelmed on a constant basis,


Speaker 3 48:29

I am overwhelmed on a constant basis, your your group. So I, when I'm on service, my days, I get into the nursery about 630 in the morning, and I examine all the babies, I look at lab data, I talk to our nurses really important. One of my favorite phrases, you can learn everything about a baby in three minutes by talking to a nurse that would take you three hours in front of a computer. So I tell our residents talk to the nurses, they know what's going on. And so all day I come back to my office, I have to, as you know nowadays with three long notes that we use epic at Columbia, and I put my notes into epic. And then at the end of the day, make rounds again, with my fellow going over all the cases. And then at that point, I'll either go home or work in my office, trying to do the things that I've not done that are part of my schedule. And if that involves editing, or writing, I'll spend an hour or so after the day. And when I go home at night and on weekends, after dinner or or free time on the weekend. That's when I have the time to do the editing and writing that I've not done during the week. But there's no easy way as well. I can say there's no easy way and I get frustrated just like everybody else and I feel overwhelmed by the things I have to do and I'm pretty good. I'm a multitask Esther that helps a little bit, you have to be I go from one project to another, do something, make a change and then go back to a third project or to the original project, right? I found that I can do that in my career.


Daphna 50:16

It sounds like your family is also really important to you. And I, you know, how, you know how I've to craft a two part question. So how do you, you know, balance being able to because it sounds like you're writing, editing, working, you know, every day of the week, like so, so many people are. And my follow up question is, is, do they know that you're basically a celebrity in neonatology? Oh,


Speaker 3 50:46

that's a very interesting question. So you may know I won this award when the Apgar award in ecology and it was a great honor. And when I have had a virtual award session, and I have said publicly on more than one occasion, I could not have accomplished 1/10 of what I accomplished in my career without my wife, being the match a bed word glue, but being the person who really runs our family, from start to finish. And I don't think you ever know what your parents really do for a living. I know my father was a teacher, maybe that's why I like enjoy education, or principal. But I'm not sure I knew what he did on day to day basis. And my kids knew I worked in an ICU, but never really understood. And they all came when the app card award was given a virtually a few weeks ago, and Richard Martin and a friend of mine presented the award and heard what I did in my career. So I think for the first time, they may have heard, what I really do for a living, not really understanding what someone on the outside would say what neonatology or intensive care is all about. And my kids growing up, we know that I was busy. And if I came home at seven o'clock at night, that's when we had dinner, I can't wait eight o'clock, that's when we have dinner with my kids. We'd never eat first. We always had that time together as a family, where we talk about everything, we're nothing. And so my kids knew that they were part of me being successful. And they would do things before and so they were flexible. In terms of my own career. So my kids now know, I think what I've accomplished in my career, but I'm not sure they still understand what I do. Really, in taking care of babies and the ethical issues and the other problems that we're all faced with in our careers, they don't understand that. But they loved hearing and even my daughter in Australia, listen, hearing the accolades that were given as part of the Apgar award.


Ben 53:03

I have a funny story that happened to me that exemplifies exactly what you're describing. When I was growing up in France. I was home from college, working on my organic chemistry homework. And I was struggling with a problem. And my mother, who was a pharmacist, came came next to me and solved it. And I looked at her saying, how do you know this? And and she said, What do you think I do are trained. And that's exactly what you're describing this realization. Oh, my mother knows chemistry.


Speaker 3 53:38

When I was growing up, I'll just tell you a quick story. I would do my homework. And this is when I was in junior high in high school. And my father was a principal, as already said, we sometimes work at night to earn enough money as a principal of a night school. And he would come home at 10 o'clock at night, and sit down with me and go over my homework. And then this is wrong, this is bad. This is good. But he was he took the time to do that. And that I tried to do that in my career, not at 10 o'clock at night. But things that try to help my children along the way.


Daphna 54:14

It's so it's so cool. To hear people as accomplished, especially is is you are that you have a lot of gratitude, I think for the people in your life, and you do a really good job of recognizing others. And I just think that's something we can all learn from that by raising other people up. It makes you know, all of us stronger. And I'm hopeful you can speak a little bit about that.


Speaker 3 54:45

Absolutely. I think it's so important. So whenever are our fellows presented frequently, as I'm sure where you are they present frequently. And whenever someone does something well, whether it's a research President Asian or a, just a summary of the literature in a specific area, I try to take the time to write them and tell them when a great job they've done. It's something that we do, don't do very much in our lives. Tell people when they're doing a great job, I try to tell the residents when they've done that, or medical students when they've done a great job. So picking out not picking out but identifying people who have done great jobs or even adequate jobs and giving them fun, always perfect, but giving them praise, and we don't, in our specialty, we don't provide enough praise for people who are really working hard to so I tried to do that on a regular basis.


Ben 55:46

I have one last question. And we're running short on time. So we're gonna have to wrap up soon. But I wanted to know if you could share with us what is your secret to being enthusiastic and continuing to do the work you're doing both in education and in clinical, clinical setting, at your at the state at your stage of your career, I feel like a lot of people that we speak to especially young career neonatologist even mid career, and there's this frightening assessment that you hear from people sometimes saying, I won't be able to do this for another 20 years. And the the outlook is so bleak. And then we get the pleasure of talking to great neonatologist like yourself. And like we did with Dr. Wally Carlin not too long ago, and we see this flame this passion. That's that feels everlasting. I'm wondering how do we foster that? How do we


Daphna 56:37

how do we bottle it up? And drink it


Unknown Speaker 56:41

is a good example. Because he still got the flame, I would say


Ben 56:45

yes.


Speaker 3 56:46

And if what you do is challenging and rewarding, it's got to have both of those parts to it, then you gotta eat. And there's no reason you should cut your career based on an age that you're at, and I and every day in the NICU, I am challenged. Not every case is challenging, but there are a lot of really challenging cases. And the reward is baby gets better. someone learns something new. The family has gotten through a very difficult there's a lot of rewards that come in neonatology. And yes, I get tired. And some days I'll come back and say, Holy cow, can I keep doing this, and I come back the next morning, and I'm refreshed. And we'll make rounds again and the challenges and rewards are there again. And I guess if they ever stopped being there, then I would not do it anymore. But I just don't see that happening to me. At this point in my career. My only limitation I get tired. And I guess everybody gets tired but but it's something that's the challenge isn't reward we overwhelm the fatigue that comes with working in the ICU.


Ben 58:00

Well, thank you that that's that's great.


Daphna 58:03

Yeah, my my last question is, you've seen so much throughout your career. Obviously neonatology has changed over and over again. What do you what do you think is next what's the next frontier in neonatology?


Speaker 3 58:22

next frontier in neonatology many simple answer is prematurity and doing better without. For years, we are focused on mortality and surely that's important, but the wrong focus and when families once they get beyond mortality when we baby live or die, or interested in what my baby be like as they develop it, I think, improving neurodevelopmental outcomes, either by how we practice neonatology, I have to say that my practice I try to make my practices the challenge as gentle as possible or by medical therapies. And now erythropoietin or darbepoetin is not maybe not the answer, but there are probably ways that we can improve developmental outcomes. Hyperthermia, small benefit is not clearly not the major benefit for hypoxic ischemic brain injury, but I see neuro development as the next great frontier in neonatology


Ben 59:30

must make you happy Daphna.


Daphna 59:31

It sure does. Well, you know I think it had been ignored for some time because we were tackling some of these other problems and so it does bring me a lot of joy. That is, what's up and coming. Gosh, this this hour with you has flown by I'm not surprised at all. We've had so much fun and we we've learned a lot so so certainly taught taught us something just in this last Our I know our listeners will be so grateful. So thank you so much for your time.


Unknown Speaker 1:00:04

Thanks to both of you. I've had fun to this.


Ben 1:00:08

And I want to thank Tom Hayes again, Dr. Tom Hayes for for helping us arrange this. And, Tom, if you're listening, thank you so much. So yeah, Dr. Paul, and this was amazing. And I'm sure that the listeners will, will get as much out of this interview as we did today. So thank you.


Unknown Speaker 1:00:23

Thanks, everybody. Have a great day and stay well.


Ben 1:00:26

That sounds good. Thank you



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