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#071 - Dr. Avroy Fanaroff MD

Bio: Dr. Avroy A. Fanaroff, MD was the Gertrude Lee Chandler Tucker Professor and Chair of the Department of Pediatrics and Reproductive Biology at Case Western Reserve University School of Medicine. He also served as the Director of Neonatology and physician in chief at Rainbow Babies and Children’s Hospital in Cleveland. He is currently Emeritus Professor Case Western Reserve University, and Eliza Henry barnes Chair of Neonatology. He is globally acknowledged as an international authority in the field of neonatology, and has contributed greatly to literature in the area of neonatal medicine, with particular focus on pulmonology, nutrition, and sepsis. He is co-editor of Fanaroff and Martin’s Neonatal-Perinatal Medicine and Klaus and Fanaroff’s Care of the High-Risk Neonate. Dr. Fanaroff has been recognized for his contributions to the field with numerous honors and awards, including the Apgar Award, the Professional Education Award and the National Neonataology Education Award from the American Academy of Pediatrics, and has been honored with an honorary fellowship from the Royal College of Pediatrics and Child Health in London and honorary doctorates from the University of the Witwatersrand (his alma mater) and the University of Turku, Finland.


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

Ben 1:00

Hello, everybody, welcome back to the podcast. It's Sunday Daphna. How's it going? You're back.

Daphna 1:05

I'm back. I'm back. I'm back. Um, you know,

Ben 1:11

what do I try?

Daphna 1:13

I'm, what I learned on vacation is that it's hard to take an election, right? I'm not very good at taking vacations. And we just actually talked about this in a in a recent recording is how much I love what I do. I'm very grateful to have a job that is rewarding. And helps me take care of my family and lets me walk with with other families. And, you know, I still kept in touch with some of our families, for vacation. Those babies were growing and developing and they

Ben 1:54

want I mean, can you imagine if it didn't work in the NICU, where you're kind of allowed to check out a little bit here and there. But can you imagine if you had like a practice, like a pediatrician with a group of babies, oh, you'd be able to disconnect will always be on like there's just not an art. It's just not in our nature. It's just not in our nature. We're very excited today. We have we have a legend of our field on with us today. And, and it's quite an honor to have the opportunity to chat with Professor Elroy fanaroff. We want to thank Dr. Reed Orion, who is so good to us and who's helping us make these connections. Yeah, I mean, this is this this she was instrumental in helping making this happen. And so so thank you, Rita for for helping us. I almost feel like we shouldn't even read a bio. Do we even need to read a bio? I mean, Dr. Penrose? Yes,

Daphna 2:50

we should, we should.

Ben 2:54

Dr. Fedoroff was the Gertrude Lee Chandler Tucker professor and Chair of the Department of Pediatrics and reproductive biology Case Western Reserve University School of Medicine. He also served as the director of neonatology and Physician in Chief at Rainbow babies and Children's Hospital in Cleveland, Ohio. He is currently emeritus professor at Case Western Reserve University and the Eliza and Henry Barnes, Chair of neonatology. He is globally acknowledged as an international authority in the field of neonatology and has contributed greatly to literature in the area of neonatal medicine with particular focus on pulmonology, nutrition and sepsis. He is the CO editor of federoff and Martin's neonatal perinatal medicine, and Klaus and Fenner offs care of the high risk neonate. Dr. fanaroff has been recognized for his contribution to the field, with numerous honors and awards including the Apgar award, the Professional Education Award and the National neonatology Education Award from the American Academy of Pediatrics, and he has been honoured with an honorary fellowship from the Royal College of pediatrician and child health in London, an honorary doctorate from the University of Witwatersrand his alma mater and the University of Turku in Finland. Like I said, he needs no introduction. Please join me in welcoming to the show, Professor Elroy fanaroff. Dr. fanaroff, thank you so much for being on the show with us this this morning.

Unknown Speaker 4:18

My pleasure. Look forward.

Ben 4:21

And I wanted to start with a little bit of your background for the people who may not know you, you grew up in South Africa. If I pronounced this correctly, you grew up in bloom Fontaine? Is that how we say it?

Avroy Fanaroff 4:34

No, I was born in bloom Fontaine moved to Johannesburg when I was 18 months old. So I grew up and went to high school there, went to medical school there and then did some of my training in South Africa and went to England to do boards in 1964, which is a Long time ago, went to Edinburgh, became a member of the Royal College of Physicians, Edinburgh, did an examination in London child health in London. And I then went back to South Africa, and completed my pediatric training, I actually did boards in both medicine and pediatrics in Edinburgh. And in South Africa, it became evident to me that nobody was caring for the newborns. I was at the Children's Hospital and across the road, was the maternity hospital that 3600 deliveries in the babies were on the obstetric service. And so I convinced my attending, that we would go there every day, and would be available on call if they needed us at any other time. And so I got to examine every newborn baby that was born at maternity hospital. And that was just a marvelous experience. I also trained at a hospital called bear gwasanaeth hospital now Chris Haney Hospital, which at the time, had 18,000 deliveries. There were two physicians by the name of Weyburn. And Khan, who started the premature units. Hospital was an old army barracks, and to the awards were premature awards that had room for about 40 babies. In each. There was one incubator. So what we did was the babies were all wrapped in cotton wool to keep there was a stove in the middle of the ward, and heated the ward. And all the mothers had to stay in adjacent accommodation. And they provided human milk they expressed, which was pooled, and pasteurized, and the only feeds for these babies was human milk. And the results, and we're talking now in the 1960s, for these premature infants with minimum technology was as good as anywhere in the world.

Ben 7:40

I wanted. I'm very happy that you mentioned your experience at the bar hospital. Is it you were there at the same time with your friend? John Maysles? Correct. Jeffrey? Jeffrey Maysles. I'm sorry.

Avroy Fanaroff 7:54

We were actually there different times. Oh, I see. We graduated a year apart. But we were criss crossing. So we weren't. We were not together.

Ben 8:08

What do you think this experience at Baragwanath Hospital taught you? I mean, this was I mean, I was doing some digging before this interview when I was able to see some of the pictures. It's it's a massive area. It's like you said it's it was it was take it was installed in what used to be army barracks and, and there was a lot lots of patients. And I'm wondering, I'm sure this has some form of impact on you as a physician and how you lead your career. And I'm wondering what that was?

Avroy Fanaroff 8:39

Well, firstly, it gave you an enormous experience. You saw the whole spectrum of disorders. And it gave you confidence that there wasn't anything that you wouldn't be capable, caring for. There was nothing that scared you. Between the internal medicine and PDF variants at this hospital, you saw everything in the textbook in some of the things that never yet appeared in You saw everything from all the venereal diseases, all the disorders of nutrition from scurvy, rickets Quarshie, or call which is a protein deficiency. And it was just a very vast experience.

Ben 9:43

So one more thing about this experience. You mentioned the fact that the babies were all in one room that the mothers had to stay with the baby. Obviously, we'll talk about your training with with Marshall Klaus and John kennel but do you think that this experience had an impact on on you when it came to the introduction to family centered care, when in more modern NICU, like in the US families were not allowed, right. I mean, that was a very significant contrast where, in one instance, families were not allowed in the NICU and in another's, like at the bar or hospital, they were actually needed to stay in the NICU

Avroy Fanaroff 10:22

and questionably those were two of the abiding thoughts. One was to keep the mother close to the baby goes back to what you might consider the first book of neonatology who didn't fundamentally keep them warm, and keep their mothers nearby. That was that aspect, and then the feeding of human milk. And today, this is something that we're emphasizing more and more of the benefits of human milk, especially for the extremely premature infants.

Daphna 11:07

It must seem almost comical to you, we were having this push in the last, you know, five years about just that getting parents back to the bedside, really pushing for for human milk. But that was something that, you know, people were doing at the start of, of your training. So how do you think we got, especially here in the States got so far away from those fundamentals, and now we're having to swing the pendulum all the way back?

Avroy Fanaroff 11:39

Well, the problem in the United States was fear of infection. The fear of infection meant parents don't come into the what was in an ICU, they were very primitive. I mean, they weren't really intensive care units. The head nurse was in charge of the baby. Mothers fathers not allowed into the unit. And there were consequences. One of the first studies that I did, as a fellow was, we kept a record of the visiting patterns of the parents, and we followed the babies. And you would think that if you've got a baby in an ICU, you'd be there every day, right? You don't want to leave. And that's why I love the idea of the single family rooms where the parents can stay with him. Well, we found that if the mothers visited less than three times a week, the babies were at risk of abuse, and abandonment. Just simple observation. The number of visits to the hospital was a foreboding of what was going to come.

Daphna 13:04

Wow. You also describe in your, you know, your early career where we're talking about family centered care, and like you mentioned, single family rooms, even now, as we're inviting families back to the unit. And, you know, we're trying to put them in their parental roles. But that was still different than what you experienced where the NICU mothers were really a community for one another, right? They were pooling their milk, they were sitting together in the rooms with their babies. And so how can we take those those experiences that are really lacking in our units today about about community, supporting families, by letting them support one another?

Avroy Fanaroff 13:45

Well, I think that's an important aspect. And I think that the move to kangaroo care. And early kangaroo care, has been very significant. And getting mothers and fathers involved in the care of their babies. I mean, Kendall, and Klaus who I work with, were really pioneers, and pushed for parents in allowed allowing him into the unit. And that came in an observation by Dr. Class, who was at Stanford at the time, and found that these highly intelligent, intelligent mothers with PhDs, they'd have their baby, the baby was in the ventilator. And then he found a total disconnect. They were totally unable to bond with their babies to take care of them.

Ben 14:45

So to go to go to to Dr. Klaus and Dr. Kendall, you, you you told us you were in South Africa in the UK, and then you decide to make this move to the US to pursue a fellowship in neonatal and Perinatal medicine. Right, right. Um, and you land in Cleveland, Ohio. Was that what was I mean? I'm curious as to why Cleveland?

Avroy Fanaroff 15:10

Well, my boss in South Africa had actually arranged for me to go to Toronto with Paul Swire net was one of the leading neonatal units. And then I got a letter from Dr. squires saying that his fellows were not leaving, didn't have the funding, I was have to come the following year. I just got married. And we were eager to go in 1969, not in 1970. So I applied for different jobs, and got a very warm letter from Dr. Class of acceptance. We didn't really even know where Cleveland was. At the time, it was the seventh largest city in the US today as of 50. But it's a wonderful medical center. And I went for one year, which became two years which career so

Ben 16:21

after they're very happy that the way things turned out,

Avroy Fanaroff 16:24

the man proposes and somebody else disposes.

Daphna 16:30

I'm hoping you can give us an you know, I think for people who are new to neonatology, we are so we feel we're so technologically advanced, and we are, but I think it would be helpful to have people understand how much neonatology has changed, you know, over the course of your career, I mean, we're such a young specialty compared to medicine as a whole.

Avroy Fanaroff 16:56

Okay, I'll give you a couple of examples. Firstly, delivery of oxygen. We didn't have good monitoring, we certainly didn't have the pulse oximeter. We didn't have the Transcutaneous oxygen technology. So you were just running oxygen and know what the blood levels were. It so happens that one of the techniques we used early on was to deliver oxygen with a funnel. We adhered of the nose and mouth. And what we didn't realize is that we were inadvertently giving them CPAP. Yeah, that's probably quite helpful, but we weren't monitoring the oxygen. Well at all. And then we got blood gases. Well, to do one blood gas. You needed five ml of blood.

Daphna 18:01

Oh my god. Oh, my gosh. So let's now now we do it with the heel stick. Right? It's

Avroy Fanaroff 18:09

it's a couple of drops. Well, yeah. How many blood gases can you do? If you draining the baby? Yeah, back to calmness, cause of anemia. And as she was the blood draws, and so miniaturization of the blood gases in electrolytes and sugars and things was a made for

Daphna 18:34

electrolytes. I mean, you you weren't even able to monitor electrolytes.

Avroy Fanaroff 18:39

Well, the IV fluids were in one liter bottles. And you didn't have the pumps that you have today. Of course, there were those little rat you adjusted. And if inadvertently, the ratchet was open to why'd you would fled the baby and put them into pulmonary edema. So the new technology, the pumps, the Transcutaneous oxygen monitors, the biggest events was really the pulse oximeter. That really was a breakthrough.

Ben 19:22

And when was that? Pretty much standard, right? Because I was trying to look exactly as to what year was that? But obviously, there's the date in which it's, it's discovered and it's patented, and all that stuff, but when was it common common practice in the NICU?

Unknown Speaker 19:36

Alright, so it's in the 1980s.

Ben 19:39

Wow. So really not that long ago.

Daphna 19:41

I mean, those are things that we just take really take for granted, you know,

Avroy Fanaroff 19:49

for granted, but that was a major thing. Now CPAP the base was CPAP was a study that was actually done in Cape Town by a physician by the name of Vincent Harrison. And Vincent Harrison showed that if a baby was grunting and the grunting is helping them maintain the tidal volume is preventing total collapse of the lung in exploration. And if you put an endotracheal tube in, you stop the granting, but the oxygen tension felt. So he showed that the granting was beneficial. And towards Gregory instituted CPAP and published the first article on CPAP. In the New England Journal medicine, if you go back and look at that article, it would never be published today. Why is that? Because it was not randomized. This was a series of patients. And I think the number is probably around 15. He just showed that the arterial oxygen tension rose with the CPAP. And it was a major breakthrough shortly after his publication, which was going to pure pediatric research meetings. Everybody was looking for ways to do CPAP.

Ben 21:42

I wanted to ask you, I think I heard in one of your interviews that even at the time ventilators were adult ventilators correct so so so there was no obviously, I mean, what we use today, these These ventilators designed for neonates, that was not obviously available. And so you were using adult ventilators to ventilate premise

Avroy Fanaroff 21:59

that absolutely correct. And if you think about it, it's a disaster. The tidal volume of a three kilogram baby is what 21 Is that how much you want to deliver in the smallest thing on the ventilator is 250 or so you're barely touching the knob to deliver the volume. And guess what? Half the babies got? pneumothorax. sheep's Sure.

Daphna 22:35

Absolutely not.

Avroy Fanaroff 22:39

And it was just, it was one of the reasons Dr. Class didn't like to ventilate babies is because he had polio when he was and so he had a flail right on, and it was hard for him to intubate. So he was always looking for new ways of speeding, respiratory failure without having to intubate.

Daphna 23:12

But that's so interesting, though, I mean, given what we know now, that was the right thing to do for for many of those babies. Yeah.

Ben 23:21

And I'm sure at the time, the ET Tube leak was your friend and I wanted you've mentioned, you've described this era that we're talking about right now as the era of anecdote and anecdotal, anecdotal medicine, where where you really didn't have randomized control trials, and you were going by experiences a person's experience with a certain technique or with a certain intervention. Is there when you look back on this era, obviously, the data was not always present. But is there what do you take away from this from this moment in time where where care for these premiums were driven by experience and not so much by a large randomized trial?

Avroy Fanaroff 24:05

Well, I think the the era of neonatology and unfortunately, science was not really applied in the early days, and there were many disasters which you're familiar with. If you go back in the 50s, particularly with the antibiotics well intention because babies were getting infection particularly the preterm babies, but the sulfonamides displace bilirubin and produce connectors. chloramphenicol caused liver failure other antibiotics cause deafness, tetracycline stained the teeth permanently. And even the code care if you're familiar with the story of Pfizer Hecht, but the commonest cause of infection, the 50s was Staphylococcus aureus. And the source of the infection was mainly through the cord. So we started bathing the cords, with Pfizer hex. And this was fine. You gave one birth to a full term, baby. You use Pfizer hex, nothing bad's gonna happen.

Ben 25:47

What's Pfizer hex?

Avroy Fanaroff 25:48

It's antiseptic. It's

Ben 25:52

like some Clorox

Daphna 25:54

family. Yeah,

Avroy Fanaroff 25:55

it's in the cool hexylene family. And so you not take a premature baby was very transparent skin absorb things, and you bathed the premature baby in Pfizer hex. And you don't have CT scans, and you don't have ultrasound, and you don't have MRI. And you don't learn until somebody does it or guinea pigs, and then you start looking at babies and find that you've caused cerebellar lesions from the Pfizer hex. And there were just too many of those kinds of problems. The only good thing in the 50s was Bill Silverman did a series of studies, randomized trials on thermal regulation, and showed the importance of keeping the babies warm. The concept is a neutral thermal environment. And that it wasn't humidity, it was temperature. So he sorted that out very nicely. And Virginia aapko described her scoring system. And I think those were some of the main points.

Daphna 27:18

I love this, maybe you can, you know, give us by decade, your major accomplishments, this is cool.

Avroy Fanaroff 27:27

In the 60s, we started doing a little better. And we still had some problems. One of the things is that the formula in the 1960s stressed the red cells. So there was hemolysis, related to the fatty acids in the formula. And if you gave them vitamin D, and this was Frank OSCEs work to stabilize the red cells and they no longer continued to Himalayas. However, somebody said, Well, if you've given them oral vitamin D, surely if we give them an intravenous vitamin E, that'll be better. Well, it wasn't it was worse, there was an agent called fair evil. And it was given intravenously, and it caused liver failure, and death. And that got taken off the market, the people using different kinds of resuscitation equipment, and that was proven not to be valuable. And the other thing in the 60s related to oxygen. It was actually in the 40s that they discovered the relationship between oxygen and what was called written off as retro lentil fiber plays here, which we now call retinopathy of prematurity. And so they said, Well, okay, if given babies too much oxygen causes this retinopathy we need to restrict the use of oxygen. So in the 60s, there was a period of restriction for the use of oxygen and cross showed that for each case of blindness that was prevented probably 16 babies died on the day of birth because we wish restricting oxygen

Ben 29:36

we just reviewed that exact story on the on the on our podcast and it's an it's a it's a very interesting era of neonatology between the like this, this illustrious city between our relationship with oxygen were initially free flowing, then restricted and so took us took his time as a field to figure out exactly what what is our what is potentially the best practice and we're still

Unknown Speaker 29:59

done. No today, right?

Ben 30:01

And we still don't know. So since we're talking about about research, you are a founding father of the NI CHD, neonatal Research Network. Can you tell us a little bit about when the neonatal Research Network was created? What year was that? And what was the drive? What was the incentive to get this, this started?

Avroy Fanaroff 30:27

Well, it was started in 1996, there was a proposal that you had a present. And a number of places, submitted their proposals. Eight centers were actually funded. And it was 1986 was funding the first studies was started in 1987. And the first study that we did, I was actually the principal investigator was the use of intravenous immunoglobulin to prevent nosocomial infections. And we had to stop midway, because there was some issues. There was a concern that the placebo group were having problems. And eventually, we studied over 2200 babies. And it's the most disappointing day in my career with our really Washington, and was given the results I was given the booklet, The, what we found was that in the controls, the rate of infection was 19%. In the IVIG, group, it was 17%. So, the routine use of intravenous immunoglobulin was not a good idea, all those smaller studies at all, that it was very effective, there were 10 studies that had shown it to be effective. And this was clearly very disappointing, they've been subsequent studies that have all found exactly the same thing, that you really need a designer, intravenous immunoblot, that's going to account for the specific organisms that are going to be encountered. But it was a great study, and we learned a lot. And one of the things that emerged in that study was that it was Mark center variability, both in the rate of infection and the types of infection. And this has been a feature of all the subsequent studies in the network, that is marked center variability. And we continue to look today for the magic potion. What is the unit with the lowest rate of infection, and the best results doing differently to the unit with the highest rate of infection, and the worst outcomes, and we translate that to RDS PPD, NEC, whatever. And we're still looking for the end for the so called magic sauce. And I think we've seen a lot of improvement with the quality improvement project, standardization, of approach, and I think this has been particularly effective with infections, the bundled care has made a big difference.

Daphna 34:23

I actually have two questions about that, you know, there are lots of academic centers who may not value Qi work in the same way as like bench research. That's unfortunately had has been my experience in some instances. So what I hear you saying is really promoting the value of those of those interventions. And I guess what do you say to two senators that aren't valuing the work and to people who are really interested in the work but aren't getting the support they need to do that type of work?

Avroy Fanaroff 34:57

Their academic snobs? Uh, I think that Qi is terribly important. I think it goes amongst our major advances. Because it is teamwork. It is building teamwork. It is building a consensus. It is building a standardized approach to things. And it has made a big difference. If you go back to the 1986 87, when we started that study, we're saying yeah, a 20% rate of infection is in the similar birthweight today is 0%, is what acceptable in any infection is unacceptable. And I think Qi has played a major role in that. There's different aspects to academia and body is important. It's important to be doing bench research, it's important to be doing Human Genome Research. It's equally important to be doing clinical research. And I would heartily encourage anybody and everybody to be participating in QI projects.

Daphna 36:28

That's awesome. Thank you. I also, I love how you mentioned how hard it was for you when that IVIG data did not come out, as you know, as maybe you had anticipated or hoped. And we talk a lot about you know, resilience on our on our podcast. So how do you recover? How do you move on to the next thing, or resubmit the next paper? How much? You know, how much time do you take before beating on again?

Avroy Fanaroff 37:02

Well, firstly, I'm gonna go and address the thing about the paper, you have to recognize that you can be rejected. We're all very spoiled, you know, we, in high school, we did well, in college, we went to medical school, we did our residency, and we would reject it. You submit nautical to the journal, and it's rejected. And you've just got to have thick skin you've pre submitted. You know, you also have looked was not be wedded to every sentence that you write you gifted others have different ideas. We had an article, it was an editorial, in fact, that we submitted to the New England Journal of Medicine, and it was published by them. And my colleague, and I spent a lot of time wordsmithing every sentence and carefully and they accepted it. And they sent back the editors correction, you know, they've got this group of just edit the articles, not the editorial staff. They have is the group of editors. There wasn't one sentence. And all you got to say is okay, they're publishing it, they wanted their style. That's fine. So the answer to your question is, yes, you've got to have thick skin. You've not to be wedded to something that you're writing be acceptable to changing it. And you also have to question things. You can't accept everything that people tell you. You want to be a pain in the baton, say, what's your source? What's the evidence for that? Is that really true? And it's, it's only by doing that, that you'll move ahead because you just kept the current status quo. You're never gonna make any advance. You got to be thinking outside the box. You got to be questioning why, why why?

Ben 39:48

Yeah, this this, this mentorship that you're providing us reminds me of something I read in the book, think again by Adam Grant, where he talks about his discussion he had With Nobel Prize winner, Danny Kahneman, and then he can even says that he changed his he changes his mind at a speed that drives his collaborators crazy. And he says, my attachment to my ideas is provisional. There's no unconditional love for them. And I think it echoes exactly what you're saying. That's

Avroy Fanaroff 40:17

a wonderful quote. And my mentor, Marshall class was one of these guys who really could think outside the box and His career spanned a number of different things. For example, he discovered the lipid in surfactant, in addition to all the other things,

Ben 40:42

that was more feet switch,

Avroy Fanaroff 40:45

attention span, was in microseconds talking on one thing, and he move on to something else, and you say, what's wrong with this man? I'm talking about jaundice. And he's talking about maternal bonding. Okay. Then the relation to Jordan.

Ben 41:07

I wanted to ask you about your career as a researcher, and we've talked about it, obviously, but I wanted to ask you a specific question, because we interview many people. And sometimes you can associate a name with almost a disease or a treatment. But in your case, you're very hard to pinpoint. You've touched on everything. And I find this to be fascinating. I am wondering if you could explain exactly how do you keep up this, this constant bouncing around and keep your curiosity alive? And how do you? What do you say, to trainees who are being asked on the first day of fellowship, like, pick an area right, when, when when we're looking at a career like yours, it seems that it seems tremendously enjoyable to just go from respiratory physiology to NEC to long term outcomes. I mean, this is this is just

Avroy Fanaroff 41:59

exactly that. I was a jack of all trades and master. And I didn't want to be pigeonholed. I loved nutrition, I loved infection. I was interested in jaundice. And I was particularly interested in teaching and spend a lot of time devoted to that. And I'd like to comment on a couple of things. Related to that, because when we started in the field, there were people who thought there were authorities. But there wasn't the evidence. And when Dr. class and I did book carry the high risk neonate it was unique from the standpoint that we would have somebody write a chapter, let's say we had so many, right, let's say write on jaundice. Well, phototherapy was in vogue at the time. On the other hand, there was an authority on bilirubin at Johns Hopkins, and he didn't believe in phototherapy. So we got him to write point counterpoint in the textbook, which is something that wasn't done before. We also introduced new material in the form of cases. So that we thought this is a much more interesting way of reading something than just reading a boring text. And that was a very successful formula. And it it's a good way of getting people to think and not to just accept, okay, this is the way you do it. And that's the right way of doing it.

Ben 44:08

I wanted to ask you about education, because I love teaching. And I take great pride in teaching. And I'm wondering, when does the teacher crosses the boundary? When does the doctor become more of a teacher and less of a doctor, you've said in an interview, that you are more proud of the people you've trained and the babies you've helped throughout your career like that this that this gave you a more in a more sense of pride than then then being a clinician. Can you explain how this reached that? Yeah, there's

Avroy Fanaroff 44:40

a multiplier there. Because I can take care of X babies by train 20 people, and they take care each take excess 20x that you're helping and your trickle down effect There's a trickle down effect and the pride is in your academic children and grandchildren and great grandchildren. And we have a lot of fun in that regard. Because what is Wally color who you interviewed is my academic child and saying these are my academic grandchildren. And when we get together at meetings we celebrate in that in that form. But, you know, there's so many stories related to neonatology. Let's take for example, phototherapy? Well, you're aware that the observation was made by a medical student and nurse in a nursery in England,

Ben 45:55

in the UK. With that they left they left that she was she was noticing the babies that were by the window had less jaundice, and then she swapped out. And eventually they found it. And they found the tube, if I remember correctly, they found the tube that was supposed to be sent for bilirubin treatment by the windowsill. And then and then that sort of was the second hit that they were like, alright, sunlight has to do something. Right. So Sister Mary Jean Ward, right. But this

Avroy Fanaroff 46:20

is in Birmingham, England where the sun don't shine very much to start with. So now we come up with the phototherapy units. And the initial units you guys haven't seen these had these huge tubes, the fluorescent tubes, the whites, which some blue light in them, and you had a plexiglass outside them, which was filtering the UV. Now the salesman used to come in and they try and sell you a photo therapy with NASA, oh, this is a great unit. It's got UV light in it. And you'd say get out of my office you focus. The UV is dangerous, okay. But those lights, originally, we had to change them every 1000 hours. So you had a note on the phototherapy unit as to how many hours you were using them. And then you had eight fluorescent lights that you were changing every 1000 hours, which becomes, you know, let's say you've got 20 units 20 of these phototherapy units times 860 bulbs that you're changing every 1000 hours, that becomes quite an expense. The change to the modern units with the LEDs is not only more efficient, but it's also cost saving.

Ben 48:01

Since we're since we're going back to some of neonatologist milestones, I wanted to ask you a little bit about something we've touched on where we have moved away from us. You told us that in South Africa when you began the babies were in the postpartum unit. And now we're in the NICU FL I feel like what we're seeing from the 1950s is that neonatology was tied at the hip with OB and we've we've pretty much separated the two. And I feel like family centered care is trying to bring that back. But how do you think we're going to be able to without going all the way back where neonatologist don't have any place in the care of the newborns. But how do we go back to a place where we're more balanced with our colleagues and obstetrics?

Avroy Fanaroff 48:49

They have to be good listeners. We have to be good colleagues. And we have to be collaborative in our planning. And in that way we can do it. I think pediatrics was an orphan. Internal Medicine. And it took many years until pediatrics, particularly in the British Commonwealth grew into self sustaining departments. And in fact, where I trained pediatrics was a branch of the internal medicine in 1960s.

Ben 49:40

I wanted to jump a little bit since we're entering the last 15 minutes of the show. I am fascinated by the relationship you have with your son who is also a neonatologist. And from my research from for this interview. My understanding is that he was a NICU He is a NICU graduate as well. Is that Is that correct?

Avroy Fanaroff 50:02

Absolutely correct. And he is a nitrogen ik NICU graduate. He was SGA, although you've never noticed that today. And he had passed meconium. And I saw the anesthesiologist given positive pressure without suctioning him through all the makan Ium into his lungs. His X ray was absolutely classical. And quite frankly, he was born in 1969. Had he been born in 1990, he would have been on ECMO he was. Wow. So it was touch and go whether he was gonna make it or not. He, he was pre med, undergrad, and then had a month off and studied for the LSAT. And he say he went to law school first. And at the end of his second year of law school, after he'd worked at a large firm in Chicago, and Procter and Gamble, he said, Dad, I love law school, I hate what lawyers do. So well, you're gonna graduate law school, and do the BA and then you can move on, which is what he did. So as a senior law school, he did his organic chemistry, and did the MCAT and was admitted to Case Western Reserve medical school. Then he says, he's doing obstetrics. And I said, Well, I don't think that's a great idea. But he changed his mind in the first year when he saw that there was a shift towards wanting female obstetricians. And so he came and did pediatrics. And then I said, Do suddenly with a better lifestyle. Biology ology in his head? No, that's what I like. And as a title fellow, he commuted to Chicago once a week, and studied ethics with a group. And so he's a neonatologists, with no degree. Program, drama.

Daphna 52:52

Yeah, his path worked out then doing law, medicine,

Avroy Fanaroff 52:57

we've worked together very well. And we've done the textbook that Marshall class, we've done two editions of that together.

Ben 53:08

I wanted to ask you about that, because I think it's such a poetic story where you work on this textbook with your mentor, Marshall, Klaus, and he unfortunately passes away but you get to then share this experience with your son who is in the same field as you can you tell us a little bit about like this legacy, where it goes from your mentor to you to then your son, I mean, I think it's pretty unique and quite interesting.

Avroy Fanaroff 53:30

It, we've, we've had a seamless working relationship, there's never been any tension. There was never any tension with him in the division. Because I did not make the decision for him to be accepted as a fellow, or to be recruited to the faculty. This was all done by my colleagues. And John and I just work together very easily. And it's indeed a great pleasure to be able to work with your son. And in fact, we were able to put photographs of my granddaughter's on the cover of each of the additional books.

Ben 54:17

Oh, that's, that's who the babies are. Okay, that's cool. I didn't know that. I don't know if I would have such a smooth working relationship with my dad. It tends to be pretty fiery. We're both very opinionated people. So kudos for making that work. We both

Avroy Fanaroff 54:31

have very even tempers. So. That helps, but I think you've raised one other point that I'd like to emphasize is that mentorship is so important in your career. In choosing a good mentor, don't rush into choosing your mentor during your fellowship, because your mentors your friend for life. A colleague is your sounding board. And it's wonderful to have a good mentor. And it's important that you do have a good mentor.

Daphna 55:14

Yeah, it's obvious that you have so much admiration for your academic family as you as you call them. And I wonder if you feel like there has been a shift in trainees and mentorship where, you know, before you would pick up, potentially pick a program, because you've picked a mentor, not the other way around. And it seems sometimes with all the pressures that some of our mentors have, that that relationship is not the same as it as it once was safe, say during your career,

Avroy Fanaroff 55:51

you know, I, I think that times have changed, and they will continue to change. And the modern generation is not like our generation. When we were working, if somebody got sick, you just picked up the calls and you there was no questions asked, when you took a job. You never asked, how much time am I going to get off work on my vacation, and you barely asked what your salary was going to be. In fact, a number of people took jobs without knowing what the salary was going to be. Today, out front is, what's my salary going to be? How much time am I going to be getting off? Do I get paternity leave? Do I get this, that? And the other, it's, it's a different mindset. The if I do a call for you, you've got to do a call back. For me. It's, it wasn't like that, in my day.

Daphna 57:12

Yeah, and you, you speak about these kinds of bargaining chips. And it seems like you have a very good relationship with your family, and that your family is important to you. And you have on top of all of your work, a myriad of, of hobbies. So how did you navigate that then, with kind of a work life balance?

Avroy Fanaroff 57:33

Well, most of the work gets done at night. And so family time is important. And personal time is important. I think exercise, tennis, squash, whatever else. Me need running, jogging, walking, golf, when you get older, because it's the most frustrating game. It's all of these things are important. And, above all, to be a good listener. Don't be giving people answers all the time. And clearly, you know all the facts. And maybe they'll think of you as a procrastinator. If you're asked a question, and you're not answering it immediately, that I think before you make decisions, gather all the facts, make sure that the evidence is strong. And, you know, sometimes you've got to balance, what is going to be harmful? What is going to be beneficial. Does the benefit outweigh the home? And above all, first, do no harm.

Ben 59:03

I were coming to the end of the show. I had had maybe two more questions that I wanted to ask you. I wanted to go back to what we were discussing earlier when we were talking about your son being in the NICU and I feel like having a child in the NICU definitely at least changes your relationship with the ICU. And I am wondering, how did that experience impact you both? Both, I guess not both. What how did this experience impact you as a neonatologist?

Avroy Fanaroff 59:33

Well, I think it made me a kinder neonatologist. It made me one more aware of what it's like to be a parent in the ICU. At first, I was trying to be both the physician and the Father. And they banned me from looking at the medical record. It was very good decisions but you They an infant in the unit, you're a father, you're not a and, but I think it did make me a more compassionate caregiving physician over the course of my career. We in the early days, were not cognizant of pain management, to the same effect as we are today. And in fact, I am ashamed to admit we used to put in chest tubes without any anesthesia. And then my late colleague, Maureen heck, with an auto accident, and she got a hemothorax. And she had a chest to placed. And she said, we are primitive chest tubes with giving local anesthetic, she said, You have no idea how painful this is. And so that gave us some insight and pain management, we became much more acutely aware of pain manage, episodes.

Daphna 1:01:16

And that that relates a little bit to my last question, I'll let Ben close out the show as we usually do. But you know, we've talked a lot about the the mistakes we've made along the way, which ultimately have led to huge advances in saving, you know, millions of babies. But at a time, like right now, where there's a lot of mistrust in the medical system, and how how do you think we can help people understand and come to terms with how, you know, the history of medicine impacts the amazing work that we're able to do today? And, and like you said, you've you've written so much, you know, on on ethics with your son, and, you know, how do we how do we balance that by saying, you know, we have experimental things that we think will change how we treat people forever. And, and we're not always right, or it takes some missteps along the way.

Avroy Fanaroff 1:02:22

They're good education, communication, transparency, and we have to hammer in, that pediatrics does best with prophylaxis. And there are many examples of that, starting in the newborn period. I think the biggest example is the hep B vaccine. Because of the long term impact of that. But prevention is the approach that we've got emphasized and we've got to have people educated. I cannot get into the minds of the anti vaxxers.

Daphna 1:03:13

It's always interesting to hear it. neonatologist talk about prevention, since so much of what we do is really reactive to disease or to pathology or physiology. What are ways that you think that neonatologist in the future will be you know, bigger advocates prevention wise,

Avroy Fanaroff 1:03:33

I think the unraveling of the human genome is open many pathways. And it's not necessarily prevention, but it's early recognition of some of the severe illnesses.

Ben 1:03:56

Well, that was my my last question Daphna. So I was wondering, I was wondering exactly that. I mean, I know in the past, you've said that the future of medicine is personalized medicine. And I was wondering if you still believe that considering all the things that we've seen in the last decade or so. So yeah, so I think I think you partly you answer that. Dr. fanaroff. Then if if, if I get to ask the last question, then what is your secret to being such a an amazing educator?

Unknown Speaker 1:04:31


Ben 1:04:34

We've, we've heard that now, many times over from the greats, it's the key. Okay, I think I like that I'm gonna I'm gonna leave it at that. Definitely anything else before we close out the show?

Daphna 1:04:48

No, just, you know, you again, your career has spanned almost all of neonatology. And if you have any kind of words of advice for we have A lot of trainees listening to the show you've shared a lot of wisdom. But any other things you think people need to know,

Avroy Fanaroff 1:05:08

I think we're very privileged to be in a position to take care of the sick babies. It's a real honor. And you should remember that and to remember that words are like a sword. Think of them carefully before you use them. You should also realize that your facial expressions when you don't use words are being read by the family. You have to try and present a happy face to the

Ben 1:05:50

doctor every fanaroff Thank you so much for being on the with us. This was amazing, amazing, amazing. I'm sure the audience will enjoy this interview tremendously. I guess we will be seeing you very soon at the sand conference. So can't wait to meet you in person. Thank you for the time you took to talk to us today. 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. NICU, 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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