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#106 - Dr. Susan Hintz MD, MS Epi

Susan Hintz Incubator Podcast

Hello Friends 👋

Happy new year from all of us at The Incubator Podcast. We are so excited to kick off this year's series of episodes with a fascinating conversation we had with Dr. Susan Hintz from Stanford. She is a giant of neonatology in the making. She took the time this Sunday to share with us some career advice, her perspective on collaborative work, and her comprehensive view on neurodevelopmental outcomes. We hope you enjoy this episode. Happy 2023 everyone!

Don't forget to secure your spot to the Delphi Neonatal Innovation Conference this March in sunny south florida here:


Bio: Susan Hintz, MD, MS, is the Robert L. Hess Family Endowed Professor, Senior Associate Chief of Neonatal and Developmental Medicine at Stanford University School of Medicine, and Director of the Fetal & Pregnancy Health Program at Lucile Packard Children’s Hospital Stanford. Dr. Hintz is a neonatologist and perinatal epidemiologist, whose investigative work focuses on understanding and improving morbidities and neurodevelopmental outcomes for extremely premature and high-risk infants, including the use of neuroimaging as a biomarker. Her work as the lead principal investigator for neurodevelopmental outcomes with the Eunice Kennedy Shriver NICHD Neonatal Research Network encompasses follow up of high-risk infants at toddler age through school age. She is principal investigator and medical director for the statewide California Perinatal Quality Care Collaborative (CPQCC) High-Risk Infant Follow-Up program, a statewide partnership with California Children’s Services, integrating a continuum of care framework for quality improvement from NICU, to discharge, through early childhood. Dr. Hintz also led the creation of the Fetal and Pregnancy Health Program at Stanford and has been Director of the program from its inception. The program has established an innovative, multidisciplinary, and highly integrated approach to comprehensive care for complex fetal patients, expectant mothers, and families.



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

Ben 1:01

Hello, everybody. Welcome back to the incubator podcast. Happy New Year, everyone. Definitely. Happy New Year to you. Yeah.

Daphna 1:07

Thank you. I know you had a long week on service.

Ben 1:12

Yeah, it's okay. I it's just it's weird to work in the in the new year. I think it's always it's always bizarre. Everybody else, you know, is off. And, yeah,

Daphna 1:27

it's, you know, it is a weird time in the hospital, right? Because there are a few parties. There's like a skeleton crew. And you're right, everybody else is off. But yeah, you know, your friends can be tough times, I think. I think it'd be tough for people.

Ben 1:47

But then I was talking to the other day to Joshua Tree near who we had on the podcast before from Buffalo. And I stopped complaining because then I was like, yeah, she's like, you know, as far as the eye can see. I was like, okay, Josh, are you feeling lucky? Yeah.

Daphna 2:05

And the means that, you know, Florida's winter has ended or true, you know, we put the AC back on today. And yeah, that's it went swimming.

Ben 2:15

That's it. It did, it did snow for a hot minute, I saw a video, I saw a video of like people attending the football game at the, at the Hard Rock stadium. And they were like, there's like barely some snow falling. But anyway, Happy New Year, everybody, we hope that you guys will get a lot of things done this year. This is where your productivity buddies, basically. I mean, that's overall, we're hoping that all together, we can sort of AMP each other up. And we like if we're gonna get some get some stuff done this year. We have already an amazing lineup of guests. For this upcoming year, we have a few series of special episodes, we're going to be attending a bunch of conferences. It's going to be an exciting year for us. And we are hoping to make this an exciting year for you as well. So Daphna, what should we talk about we have some updates, first of all, so obviously, if you haven't caught up our last episode, we went over a lot of the things that we're working on some of the updates, but the thing that probably matters to you most is that we do have our end of year giveaway. It's a fully decked out iPad Pro, which I actually received the other day. So it's at home, and it has like the 12.9 inch to the bigger iPad. It has like I can't

Daphna 3:37

I can't tell you guys how excited Ben was just ordering it. So I can I tell you, the wily enjoys it really and

Ben 3:45

I tell you the story of why I was why I'm excited because I went on the Apple website and I basically picked the top of the line item. Right, so the line item with the pencil. We didn't think about it. Yeah, I didn't think about it. Right. Thanks to the generous sponsorship of the people sponsoring the podcast. In this case, the giveaway is sponsored by rocket Johnson. So it was great. But I remember as a kid was a kid well, I guess when I arrived in college, I was like, I had no money, right? My parents like the salaries in France and in the US are different. So when you my roommate ordered a laptop, and he just like basically went online, took a fully decked out laptop and just bought it and I was like, holy shit. Like, I would never be allowed to do that. And I was like, man, one day, I wish I wish I can I can have enough means to just do that. Do this for my kid as well. So for me to be able to do this for our one of our audience member it's kind of cool like it just fully decked out.

Daphna 4:39

I still haven't you still haven't done it for yourself, right?

Ben 4:43

No, no, I've done it for myself.

Speaker 1 4:47

I know I believe that. You're very you're very frugal.

Ben 4:52

Yeah, I mean, it's always the same because at the end of the day, you're like, I could be doing some good things with that money. Do I really need it? So yeah, so it's the, the gratification of being generous to others is so much more fun than the short adrenaline rush of getting like a brand new computer. It's just like yeah, when you

Speaker 1 5:18

do so you know, my my love languages gifts. So I love when we have a giveaway.

Ben 5:24

So anyway, so it's here, if you want to enter the if you want to enter the giveaway you read, there's like a bunch of tweets running around, and you can just retweet that and tag a friend, make sure you follow us as well. There's a bunch of people who are scamming giveaways by the way, I don't know if you saw that on Twitter. It's like a bunch of people who are hunting out giveaways. And I can see that like, there are people who are not following us who have nothing to do with neonatology and suddenly, just are retweeting our stuff just to get into the giveaway. So make sure you follow us. And if you want to get a double entry, you can send us a little email about how the podcast has sort of impacted your day to day practice. This is something that we just we just love these stories. And we thought we want to share more from the audience. And what better what better way to do this than incentivizing you to do it through this giveaway. And then if you have already registered for the Delphi conference, then you have a triple entry. So it's like you've you have three tickets in the bowl, to win the giveaway. And we have I think you have another week to do that. So that's really exciting. The last thing we want to talk about before we welcome on our guests is just letting you know that we are switching things up with the neonatology review podcast, the boards are approaching they're about a year, I mean, if you are, if you are scheduled to take the boards, you are feeling exactly the same, which is it's coming even though it's like 18 months, but it's coming. And so what we're hoping to do is that we're hoping that this year, we can go through the neonatology review books together and review some of that material, obviously, it will be probably too difficult to do to review all the books, but we're going to try to review the most high yield material based on the content specification, which by the way has changed if you don't know about that already. And and so we are going to get our first episode to be airing this month. There'll be one week episode one week long episodes, once a month, until the end of the year. And we have some great news from that front, thanks to the folks at KZ. We are most it's not finalized yet. But hopefully we can start waiving the subscription costs and make this accessible to everyone. Super excited about that. And yeah, I think

Daphna 7:43

especially for people who are getting ready for the Board's for new fellows, I think this is going to be I think super high yield. It's going to be like low pressure, right? Because we're starting so early, hoping to get all the way through, really the core material January through December and then pick up like we did when we started the board review podcast to do really question Question questions for the last three months.

Speaker 1 8:16

It's exciting. I'm kind of excited, especially since I don't want to take it's exciting to prepare.

Ben 8:23

It's always more fun. I often do that after exam, you know, you you read you open the book and oh, that's actually quite interesting. So why was I not that curious? Yeah. Why didn't it was why did I never have this one. I took the version. There's a version to the book during the study time anyway, we have to get moving. And we're very excited to have a marquee guest for this first episode of the year. We wanted I mean, we have the pleasure of having with us today Dr. Susan hints. And she is she is an amazing, amazing researcher, neonatologist and we think you're really going to enjoy the discussion that we've had with with Susan. And for those of you who don't know who she is, you must have seen that name on papers because she has written landmark papers, but I'm just going to go through her her bio. Before we introduce her. Susan hence is the Robert L has family Endowed Professor, Senior Associate Chief of neonatal and developmental Medicine at Stanford University School of Medicine, and the director of the fetal and pregnancy health program at Lucile Packard Children's Hospital at Stanford. And Dr. Higgins is a neonatologist and Perinatal epidemiologist whose investigative work focuses on understanding and improving morbidities and neurodevelopmental outcome for outcomes for extremely premature and high risk infants including the use of neuro imaging as a biomarker, her work as the lead printer Blue investigator for Northern mental outcomes with the Eunice Kennedy Shriver NIC HD neonatal Research Network encompasses follow up of high risk infants at toddler age through school age. She is principal investigator and Medical Director for the statewide California Perinatal Quality Care Collaborative. The CP cucc high risk infant Follow Up program a statewide partnership with California Children's Services integrating a continuum of care framework for quality improvement from NICU to discharge. Through early childhood. Dr. Higgins also led the creation of the Federal and pregnancy health program at Stanford, and has been director of the program from its inception, the program has established an innovative, multidisciplinary and highly integrated approach to comprehensive care for complex fetal patient, expectant mothers and families. Please, without further ado, join us in welcoming to the show Dr. Susan, hence. Dr. Susan, hence thank you so much for being on the podcast with us this morning.

Speaker 3 11:02

It's a great pleasure and an honor to be part of this podcast. Thank you.

Ben 11:07

The honor is all ours. You are a I guess it's it's it's appropriate to call you a Stanford neonatologist because you you trained your entire career at Stanford. And it's almost part of your identity. I guess at this point, what was the we like to ask that question to our guests? What was the thought behind pursuing a career in neonatology for you?

Speaker 3 11:32

Well, that that is a long time. Yeah. Well, I really felt like I I guess I would say that medicine was on my mind from the time I was sort of young, I thought that would that would be the direction I'd want to go maybe even from seventh or eighth grade. I thought that would that would be but I don't think that's rare. I think a lot of people sort of start thinking that way. I did think for I mean, I thought really from the beginning, I wanted to be a pediatrician that that that made the most sense. And actually, for a long time, I thought I would be a general pediatrician. But as I got further into medicine, and certainly even starting from my internship here, I realized that I've really enjoyed much more, I enjoyed Intensive Care Medicine, in one way or another. So I really enjoyed neonatology. Although I think many of us our first rotation is fraught with stress and anxiety I actually did. This is going back like into the prehistoric days, I did what was then sort of the only, I guess it was the first time anything was sort of a sub internship in neonatology when I was a medical students for a number of very bizarre reasons like they were going to be down in in turn, and people knew that I really enjoyed that area when I was doing rotations in clinical, my clinical rotations in medical school. So it was sort of like, Would you do this and just act like an intern before there was really a sub internship way back when. So I really enjoyed that a lot. So I think that influenced me greatly to think that probably neonatology would be my my way to go. But during residency, I did feel like maybe pediatric intensive care maybe even came ONC because that was getting increasingly intensive and a lot of the children actually ended up for a short time anyway, in intensive care. And I could see that would be a very important field to be in to really be able to give those kids the best care in collaboration with the, with the PICU teams. But and then I was a chief resident and I was still away again, there was not a there wasn't the same process now, as there is in fellowship. So I was still even a little bit undecided when I was a chief resident. But you know, the deal was sealed by the time I finished my chief residency.

Ben 14:22

But it's interesting what you're what you're bringing up, right? Because it is the opportunity as a lower level train, you're right, meaning you were not a fellow you were not a senior resident to have the opportunity to take to take on more responsibilities within the NICU in this case, that give you this this push. And I think we're so reluctant sometimes to push our trainees to take on more responsibilities because we want to make sure that it's not too difficult and we might make sure they have a good experience. But sometimes the opportunity to take on responsibilities is the thing that will eventually light the spark and and be the determinant of your future career. So that that, to me is very, very nice to hear.

Speaker 3 15:05

Yeah. Well, I'm not saying that the way that I did it is necessarily or the way we all were doing it back then was necessarily the right way either because, you know, I think you both would agree that there's got to be some, some balance, I agree with you, you know, the things that made the greatest impression on me, we're probably in the midst of really being dug in with, you know, as a trainee really being part of that team, like really feeling anyway that I was substantively part of the team. And that I was, that was my patient, and I was taking care of that patient. So that really that I agree with you that in all of the rotations that I can think of those were the most clarifying moments to me. Yeah. And the most important to me, that

Ben 16:00

this was what I meant, this is what I meant this was what I meant. In this question, I think, I think it's, it's important to, to not have a blanket approach to the responsibilities that trainees can take on in the day. Yeah,

Speaker 3 16:12

I agree with that. I think we, like I said, we would all agree that, you know, the old days are not the way to go. It was, you know, brutalizing in some of the ways in terms of what you're saying, then is sort of like it was required to be doing it not well, but there is, you know, a middle ground for, for those who are really, I mean, I think we've all probably had the experience of a trainee saying, No, really, I want to stay here, I want, okay, this is my patient, and I want to, you know, I want to see this through, I want to be part of this discussion, or I want to be, you know, even things like, you know, end of life issues. But, but it's like, not allowed. And in some in some institutions, I don't know about yours, maybe you can tell me like, you know, the duty our issues are very critically important in I think, most residencies. And, and so that's it. I think it's I think it's challenging. I think it's maybe more challenging for the trainees. And sometimes,

Ben 17:27

I think, I think to me, the duty, our discussion has to be tied with the dilemma of service versus education. So I think, as a trainee, you're always trying to balance service and education. And so I think it's important for us to when we want to, in my opinion, whenever ever asked or maybe suggested to a trainee to stay extra hours, it would have been 100%, for educational purposes, not for service, meaning, hey, we're going to have this discussion, I don't need you to do anything. There's no notes to be written, there's no consultant's. There's no line to be placed. But if you want to just stay here and see the process, then I think you would learn from this. And it wouldn't involve it wouldn't involve any tasks. And I think that, to me, is where I think you can be a bit more flexible with duty hours, if you and then the sometimes some residents have told me, I have to go and you said, Sure. Got one, it's no problem, but offered the opportunity of a completely educational experience, then that I think can allow you to can allow you to have these discussions and these opportunities with your trainees and say, Hey, if you're interested in staying, then this is this is going to be kind of nice.

Speaker 3 18:36

Yeah, I think it's, you know, I think it's hard. And I definitely do respect the evolution of training in that not everybody necessarily would present it that way. So there may be a feeling, I do totally understand why it needs to be white. Again, I'm sure that that this could be a completely separate topic with people who are much more educated than I am on the educational process for sure, especially for residents. But I do understand why the protections are in place, because not everybody would be taking the view of that, that you just you know, that you just presented. So I do understand why there have to be protection so that the trainees don't feel that they're kind of in a bind, you know, so, because otherwise, otherwise we'll be on a slippery slope back to however many deadly hours were being done every day.

Daphna 19:51

Well, and I think, aside from the duty our discussion, I think training has evolved some in that it, I feel like where I learned the most where when I felt I had all of the responsibility for the patient, but I knew that my supervisor knew everything going on with the patient. Right. So you know, that I would be asked about things that, you know, if I didn't catch it on the first go, or I knew educational opportunities to present themselves, but I still felt this burden this weight of of the of the responsibility. So I think it's a fine line. It's a tough line as an educator to to tell.

Ben 20:37

Some since since we're philosophizing. Susan, what would you have become if you were not a physician?

Unknown Speaker 20:49

I'm not a physician at all

Ben 20:51

at all. I'm Yeah, I could have gotten different specialties. But I think the answer might be more interesting. If we went outside of medicine. Well, I

Speaker 3 20:58

probably would have been a musician. Mm hmm. That was, yeah, music was very centrally important in my life for many, many, many years. So yeah, actually, I, I think that's probably the direction I would have gone. I. Yeah, well, well,

Ben 21:20

thank you. Thank you for that answer.

Daphna 21:21

No, that's cool. How does music play a role in your life still?

Speaker 3 21:27

Well, that's one thing I think I probably would have changed. If I, if I had to do over again, I would be much more intentional about staying connected to, you know, performance. So I was, I was a bass player, and a bass player, a classical bass player, so in orchestras, opera orchestras, etc. And so I was involved in many groups. Prior to actually, really prior to the clinical years of my, of my medical school time. So actually, even through that time, so it really wasn't until like residency, that my involvement in music sort of started to drop off. So and then I really, I really felt like, you know, I, you know, I can't be, I can't commit to, you know, you know, to two operas in a season or something like that, because I wouldn't be able to, you know, attend all of them be a part of all of the rehearsals, etc. So, you know, I'll be on this rotation, that rotation cetera, and sort of dropped off. But, you know, I also play piano and do a few other things. So I wish I'd been more intentional, intentional about keeping that as part of my life. But, you know, it's, you know, my, I'm still physically able to do those things. And I'm not quite, you know, yet at a point in my life, where I'm haggard or unable to do things. So I could, you know, I could probably pick it up again, but I will probably start with more personal music. I tried to teach myself like a couple of a couple of things. I taught myself how to play autoharp, which is not a great, huge, you know, you could take that up, by the way. But anyway, yeah, I think I will start, you know, getting back into music, maybe in a more personal way. But music plays a part of my life now, as I listened to music. I think that's about it at the press. But

Ben 23:45

isn't it interesting that a lot of not a lot, I would say a significant part of the work you've accomplished in neonatology came through your work with the new neural network, and this massive conglomerate of of institutions trying to collaborate with each other. Do you think that? Isn't that sort of working part of a big orchestra?

Speaker 3 24:11

Well, that's, that's a very beautiful way to paint that. I do actually think that but as I said earlier, you know, everything that I do, every everything that I do, I feel everything that most of us do, probably, but certainly everything I do, is as part of a team. So it's absolutely true in the NICU, HD neonatal Research Network. I cannot believe how you know, how well everybody works together. There is such collaboration, I mean, even you know, developing a new trial or a new project. It's not you know, even though it may come from one person sort of starting the thought, but almost immediately, most people reach out to colleagues and other places to, you know, to say, hey, can we work together on this? Can Can I bounce these ideas off of you? And it's just, yeah, it's a, it's a great, you know, it's a great collaboration. And it's been, you know, it's been really an amazing opportunity for me to participate in that into as a very young neonatologist to be a part of that was so valuable and so impactful to me how people could work together and how things could be built. And, and actually, just the embrace of young people in the neonatal in the neonatal Research Network. was inspiring, because, you know, I was welcomed into that, to that group of, you know, some really amazing big names. And you know, that that has had a that's had a great impact on my life. Yeah.

Ben 26:11

I was going to just ask them, When did your interest in NGO, we're all very passionate about neuro development on this platform. I mean, people may not know this, but I, I spent my whole fellowship, studying neurodevelopment. Daphne's continued, that she's the director of our northern dental program here. So we're all very passionate about this. I'm wondering When did your interest in neurodevelopment peak? And what was the reason for you pursuing that interest?

Speaker 3 26:39

Yeah. That's a great question. It probably goes back to my point about a career taking twists and turns. So actually started out thinking that I was going to be lab based. And as an undergraduate, actually, I was working in David Stevenson's lab and Billy Rubin metabolism,

Daphna 27:00

you have plenty of basic science, papers, publications, right. So

Speaker 3 27:05

I really thought that's what I was gonna do. And then as a fellow, I thought that well, there I was becoming obviously much more interested, as you go through training, I think all of us would say, we become much more interesting, interested in integrating, how is the brain working in this, you know, in this whole organism, you know, and what, what is what's going on there. So, I had an opportunity to work with David Benares, who has now several companies, but it was sort of on the prototype of near infrared spectroscopy. And, I mean, it was really like me welding things together. And then, you know, trying to get, again, groups of people together, including some pig studies that we did. And also some clinical studies that we did with this sort of, again, prototype of near infrared spectroscopy, that was really not only sort of the components we think of now, but there was an imaging component to, to this concept. But, but that was also a great opportunity to sort of work in big teams and actually had the opportunity, like you said, Ben, you know, when I look back, and I think, wow, somebody gave me the opportunity. Somebody gave me this, like, blank page and said, Well, yeah, I mean, you know, call these people and see if they can all come together, and you know, and soon you're in a pig lab, you know, with 20 people who are doing this work together, which is, you know, which is fascinating. But, you know, from that, from that sort of, I don't know, technology based research also led me to say, Well, what's really the ultimate interest in this? It's not, it's not just, you know, what's the, you know, what's the blood flow, what is this image, etc, it's, you know, how does this relate to how that baby is going to be managed, and also how that baby is going to do later on. So I sort of started integrating MRI as as part of kind of the research trajectory that I was interested in again, with other groups and teams, and then eventually that really put me on the path to you know, really, ultimately, I want to know what's going on with these children later. So I better learn how to do that and I better start, you know, figuring that out. And also part of that was, you know, if I really want to do this kind of research, I need to We'll learn how to do not only what is what does neurodevelopmental outcome mean? And, and, and integrate that, but also, how do I put together a study? How do I do these analyses if I'm going to be working in, in big numbers, so that also led me again, through the neonatal Research Network. I, I mean, it was a key mechanism at that time, that was called a, an M, SCADA mentored specialized clinical investigator Development Award, to get a master's in epidemiology. And in early in my, in my, in my faculty years, actually, so, so think things moved in that direction, I will say that I'll say the other thing is that I had the amazing opportunity to meet and really be embraced by some amazing women primarily in neurodevelopmental outcomes. And again, I cannot, I cannot emphasize to you how strongly an impact it made on me to have Betty voere, who is a true true friend of mine now, I mean, I at the time, she just was embracing me as let you know, let's have a discussion about this. And she of course, is a major feature in the neonatal Research Network. And how much I learned from her as well as Maureen hack who's now passed away, Maureen was such an influence on me because she was so supportive of some early projects that I really wanted to do in school aged outcomes, including extending the the neurodevelopment neuro neuro imaging and neurodevelopmental outcomes cohort have the support trial that from not not just two year outcomes, two, to six to seven year outcomes, and she was so supportive and just a wonderful, you know, mentor in that and was part of the subcommittee of that of that study. And a Suroosh Seagal is another individual who was and still is just so supportive, and such a great friend, and really without, without those three women, I don't think that I would have been able to sort of do what do what I've been able to participate in doing because they were just absolutely supportive always available for me to bounce a question off of, and taught me so much. Yeah, sometimes meeting I guess, I'm sorry to interrupt, I think definitely sometimes meeting, you know, the right people and like, through the benefits of connections, and they were also incredibly before the term sponsorship had ever been invented. They were doing that for me.

Ben 33:15

This episode is proudly sponsored by record Mead Johnson. Regularly Johnson is dedicated to the research and development of nutrition products that help support baby development at every stage, including an extensive and female portfolio for premature and low birth weight infants learn more at HCP dot meet

Daphna 33:34

Yeah, I think you speak to the importance of bullying people up, right? You know, and it doesn't. It doesn't detract from our accomplishments if we help other people succeed. And I wonder, in your opinion, you've had such landmark mentors who, you know, are big names in neonatology and about what makes a good mentor.

Speaker 3 34:00

Well, there's so much that could be said about that. I think a good mentor is available, but it's not necessarily always driving the relationship. So I think sometimes there is a there's an interpretation that the mentor is the one who is setting the agenda always. But I felt in my best mentee relationships that I was asking the man like I was, I guess I was trying to drive as I look back, maybe at the time, I didn't see it that way. But I was really trying to try to drive the discussions in the way that was best for me, although that mentor was also being very honest with out maybe some crazy ideas that I had? Or is this the right way to go or not? That mentor also needs to be quite honest with with you supportive, but honest, you know, you know, if you have the benefit of mentors who've tried things a million times, and they can say, you know, here are the five times I've tried to do that. And I'll tell you the ways that I did it, I'm not saying it's not because I'm all for it. But these ways didn't seem to work. Maybe it was reason A, B, or C. But I think the mentor is also sometimes, again, these definitions can get fluid. But I think a mentor is also a sponsor in many ways in terms of connecting you and, you know, maybe putting you in the right position to achieve the best that that you can achieve. Most of my most successful relationships as a mentee developed into collaborations and collegial relationships, and friendships. So, yeah, I don't know, I think. I think it's a two way street mentor. Relationships. You know,

Unknown Speaker 36:20

I love that. I love that.

Ben 36:21

It's not always easy to see it that way. Sometimes it's been far as a one way street, where I'll tell you how it's supposed to be. And right. I like this idea of of it goes both ways. Sorry.

Speaker 3 36:31

Yeah, no, I think I think it's true. I think some people have, I think there are different interpretations of the mentor mentee relationship, I think. I think there, I think there are many successful examples of mentor mentee relationships, they probably all work slightly different ways. But I definitely do think that it's a, you know, it's a two way street.

Daphna 36:57

I wanted to shift a little bit if I may say, so your career so far, kind of Chronicles like a paradigm shift in neonatology from instead of the, you know, treatment focus, let's manage this disease to saying, you know, what happens to these babies, after we do all these things to them for them, depending on what that might be. And, you know, was the end goal in the NICU enough to say, you know, it was met an end goal outside of the NICU. And that was really paradigm shifting, I think, and it is still sometimes hard to remind neonatologist about, like, it's not just what's happening here from the day to day, and then they go home. And we say by, you know, you made it and getting people to remember how much of a life occurs past what we do in the NICU. And so I wonder what that was, like being part of this kind of movement and saying, you know, this is something that's really important that we can't lose sight of.

Speaker 3 38:03

Yeah. Yeah. I think that's, I think that's true deaf, and I think they're still even now, people who are not thinking about that later endpoint. But I think you're right, that it is much more forward and neonatologist minds about what the outcome is going to be what I think we need to think about now, and, you know, great investigators, like any shell VA, and, and, and other, you know, investigators in psychology and psychiatry as well. You know, for instance, at Stanford, Richard Shaw, we, I think, I think we as a, as a specialty, need to really be thinking about what is what is the end point? Or are there multiple endpoints? And does it really, is it really reflected in a Bailey score? Versus Is it better that we look at an outcome from the perspective of are these families you know, whatever a family means, you know, successful is, is the quality of life. However, that is measured. Positive. And so I think, you know, in that way, we are still and we should still be evolving, and it may be that one endpoint is appropriate for us to think about in a particular intervention and another endpoint is appropriate and another intervention but I think I would also say that neonatology sometimes forgets to think backwards. So that may be one reason why some people have asked me like, well, you know, you seem to have these disparate areas of your career, you know of your life, you know, your academic life, in that I direct our fetal center, again, a big group of individuals. And I also, you know, do research and neurodevelopmental outcomes. And I also, you know, have I lead the statewide high risk infant Follow Up program for California. So that seems to be quite, many people don't see that as being connected. And I certainly do. I think many others see that as being No, it's It's actually part of a continuum that needs to be seen and actually reinforced as a continuum. All of these things that are happening in fetal life are absolutely critical for all of us in in the NICU to understand what is known what is not known what discussions have occurred with the family, where are they in that arc of understanding or where are they in terms of their preparation for what's to come? And then, you know, the NICU experience, there's really no way I think that any of us can prepare a family for the NICU experience. If you have a long NICU stay, it is that it's for many families is completely life changing. And then to sort of be sometimes shoved off a cliff, you know, and okay, now we're being now you're being discharged by that we we really, I think that aspect that that transition, some some individuals have done, some sites have done amazing work with that transition. And Betty Vora is one of them. She has a great transition Plus program in Rhode Island. And then there have been studies, as I'm sure you are aware, and studies still ongoing. There's a great study that's ongoing in Canada CCENT, that I'm very interested to know what the results of that will be. But those are all things that I think we need to evolve toward doing on a population level, which is why I guess I'm very excited that you know, we have the opportunity in California to maybe influence that kind of trajectory. So especially with the connection between the NICU data sets and the risk infant following.

Daphna 42:38

No, I I'd love to hear more. I, I I totally see that connection. I mean, that just makes sense to me, we know so many things that are happening prenatally to a pregnant person to a family impacts the NICU stay and affects long term development. And so I'm wondering, you're you obviously have had a lot of success and in kind of integrating in in ameliorating these transitions of care. What is your advice to organizations that are trying to have better transitions of care in either direction from you know, fetal to neonatal or from the NICU to home? Since certainly you're an expert in both?

Speaker 3 43:26

Yeah, I'm not sure how much I will maybe I don't know about advice, but but maybe things that might be areas of focus. So the early, you know, the fetal to neonatal. I think Stanford and and some other centers that have, you know, MFM maternal fetal medicine that's really part of the same institution have have some really great opportunities. So but but even, even in institutions where they're maybe not right there, maybe they're delivered next door, you know, there, there are all sorts of models. Really, I would say that having a foundation of, of connection between the ontology and MFM, you may think that you're connected to MFM. But really, if you don't have a routine, and maybe it doesn't need to be a whole program that I think sometimes having a program allows for some solidification of infrastructure that may be needed for both recognizing what is coming down the pike and also being able to create support structures that will allow the best kind of communication as part of that. So So, you know, we are lucky that that literally in our institution, we've been right next door to MFM for, you know, our entire history. And, you know, before you were asking, like what was, I guess, maybe keeping me at Stanford, but having that kind of integration, I don't know, for me was so important. And I just, I couldn't even imagine how I how you could do your job without having those multiple daily conversations. And that was even before you know, sort of building out this fetal center. So really, key components to that are, you know, consistent communication, there are always going to be some some, some challenging conversations between MFM and neonatology, just from the perspective of, it's hard to get to the point where you're all talking about the same thing, you know, neonatology may be talking about the baby MFM may be talking about the mother, but but you can come to, you can come to the point where you are all talking about the entirety. In terms of smoothing transitions, if you have that kind of communication, I would say, especially if you have some kind of programmatic infrastructure, you can build all that you can build all the components and bring all of the individuals into that program for, you know, specific families and specific babies. And one major component for our fetal Center at Stanford is that we have always said that social work, and housing needs to be a central component component for that. So the social workers in our fetal center program, for instance, are the same social workers that will be with that family through their entire NICU stay. So there really is that is a real point of continuum. So those kinds of transitions, and also now we're lucky that we are beginning to do much more consistent Screening for Mental health issues for mothers and fathers, and being able to build slowly, more of a mental health professional infrastructure as part of the whole Children's Hospital, which include support for mothers as well, that we are, you know, we're lucky that our institution agrees that that needs to be done, but it is very difficult, and it's a long path to be able to build in those resources, you know, at the level that they're needed, in terms of the other transitions, from NICU to home. Boy, that is a huge question Daphna because, for children with special health care needs. You know, many, many sites now are lucky to have a complex care clinic, that that is part of, of their institution. But as you know, and as many of us know, most of you know, many, many of the children who are referred to our institution for NICU care, or even prenatally an expectant mother is referred to us may not be from near us, they may be from very far away, they may be in our catchment area, they may be in our part of the state, they may not be. And so they may not have those same opportunities for that kind of level of coordination. So I think we really have to do better on a whole population based level of coordinating care for, you know, long term, truly long term outcomes, because those kinds of juggling of, you know, a zillion appointments and making sure that the services are in place that they need is a major stressor for families. And it's also a major challenge for you know, getting care for, for the children long term. That was a long answer. But as I said, it's a it's a big, big, big issue. And you know, you kind of went to the heart of it, definitely. How do you improve transitions? Oh, my gosh, it could be, it could be a multi month seminar, have discussions on how that could improve. But I think I think institutions and neonatologist really need to recognize that as a major goal for next goal for the future.

Ben 49:40

Yeah, and especially considering all the investment that goes into these babies in these families from both an emotional standpoint or resource standpoint, it feels like it feels so wasteful to just then cut, cut the cord and just not provide the framework necessary to make sure the transition happens just as well as the care that was received. in the NICU, you mentioned something about neurodevelopmental outcomes and definitions. And, and that's something that I was looking forward to ask you about. Because I think, do you think I mean, you've, you've alluded to the fact that quality of life and the perception of how families live their lives, is what truly matters. Do you think that we are going to see a change in how we assess neurodevelopmental outcomes in the years to come? I mean, right now, the standard is really to do a Bailey at about 24 months. I have many questions. I'm gonna stop here for now for just one question at a time. But do you think that's going to change?

Speaker 3 50:38

Yeah. I think it is changing how we assess our developmental outcomes. I think it also kind of depends on what the question is. So you know, let's say that the, you know, we're talking about a lot of things here, today, we're talking about sort of a population based or a broader clinical approach to comprehensive care for a child and a family. And then we're also talking about research, and it may be appropriate that a research endpoint, if there is a specific intervention, that is proposed to, you know, that that that theoretical infrastructure is that cognitive outcome is going to improve, you know, this is going to be something that's going to improve, you know, cognitive outcome, or maybe it's something that's going to protect you against, or, you know, protect you in terms of your motor outcome, it may make sense to do a very detailed assessment, in fact, that may be the only way to, to evaluate that particular intervention appropriately. So doing, you know, I might argue that, you know, I mean, a Baleia, two years, may or may not be the right endpoint, you may actually, I would actually propose that if you're doing a NICU interventional trial, you should build in later outcomes. Because we all know that there are lots of things that we can't measure very well, at two years. So, so, Bailey, cognitive may not be the be all and end all, you know, when executive function starts coming into play more and more, you know, we can't do a very good job of testing executive lecture to two years. So and that's, that's an important point, part of you know, how you are going to function on a cognitive academic level, and, you know, later on, so. So that being said, I would say that sort of more on a clinical perspective, for our understanding of how children and families are doing, I absolutely think that neurodevelopmental outcomes are going to be changing how we assess them. So for instance, in California, and many there have been many publications on this, on this point. Does it always have to be an in person Bally test? And I'm sure, you know, there's going to be a great intake of breath, you know, like, oh, my gosh, what's being said, but I think everybody knows that, you know, it's not a again, this is like differentiating a research cohort from a, from a more clinical cohort that assessments by telehealth as long as the appropriate instrument is used in home assessments. As long as you know, the appropriate approach is being taken and integrating more, you know, family aspects of of outcome makes enormous sense. And I think many of us have started to do that. Certainly during COVID. A lot of the programs were sort of pushed to, to do that. And you probably know Alicia spittle has really made amazing, great strides in terms of being able to even, you know, continue physical therapy, by telehealth in a very structured, thoughtful way. But, you know, these are things that probably differ or again, are differentiated from a particular study or trial endpoint, compared to how can we provide the most insightful and, you know, sort of, maybe the best information that will help us to support a family better, may not be a Bailey score. It may be other questions about that family and about services that are being gained. But, you know, having said that, there are you know, instruments that can be deployed by telehealth that will help us to do At least estimate and motor and cognitive outcomes. And if

Ben 55:05

a young researcher is listening to the episode and wants to develop the next great tool to assess performer preterm infants, then there's your there's your cue.

Speaker 3 55:14

There, there are tools, but but there are more that I totally agree there's a lot of running space in that. In that world.

Ben 55:21

I wanted to ask you about what I perceive to be a very controversial topic. Not that I want to make this a controversy. But I wanted to get your take on the correction for prematurity issue, right, because I think when we talk about neuro development, a lot of times we do, quote unquote, correct, which means that we adjust the age of the infant for their prematurity. And, and sometimes, I mean, if you were not to correct, babies would be perceived to be much more, I guess, behind than they should be. But on the other hand, we know that early steps, programs implemented as early as possible have the best outcome. So how do we should Can you tell us a little bit what your view is on the concept of correction for prematurity? Whether it is from the patient care standpoint, from a research standpoint, from a reporting of neurodevelopmental data? Under just curious to hear, just curious about your thoughts, you don't have to give us you have to give us a definitive statement, but I'm just curious about your take.

Speaker 3 56:20

Oh, well. There have been differing approaches currently, in our you probably know that the neonatal Research Network has is pursuing five year outcomes for the top trial and for hydrocortisone, for BPD. You may know Sarah dimauro, from chop is leading the hydrocortisone for BPD. As part of that study, yeah. And that is correcting for prematurity all the way to five to six years. And again, that is, in part based on studies that have come out from people like like sgoil, and Marlowe, and, you know, really suggesting that this, you know, if you kind of want to understand where they are, maybe you do need to, from the research perspective, correct. out to that point, from, from a clinical perspective. I definitely see your point, Ben, of, you know, what, what is sort of the appropriate thing to report when you're thinking about the services that that child is, is going to need? So, you know, if you're entering school, you want to make sure that the IEP is appropriate for that child. And I think that's a different question. You know, if I think that the correction really comes to, from my perspective, you know, comes to two things. One is, is assessing from a research perspective. And the other is how do we, how do we describe that child in the context of their peers, and what they what they may need to help achieve their best outcomes? And so that's it. So it may have different applications. Again, you said, I don't have to be definitive, maybe I don't, I'm not being definitive. But I, but I do think that there might be slightly different questions, you know,

Ben 58:35

right. This is a discussion that my former mentor, Dr. Charlie Bower, and I had on a daily basis, where, depending on who you ask, some people will want to correct some others won't. So for example, parents are the most ambivalent, they the they're happy to correct to, to have reasonable expectations, but they will not want to correct and start implementing services because they don't want to find themselves correcting at three years old, and then finding out that there's any, any near the mental delay. If you ask of working in the early steps clinic, it was very interesting. Researchers love to correct and then the therapists say no, just just start services now. So it's always it's always been very interesting as and it's, it's an issue of perception. It's how do we perceive it's a bit like the Apgar score? It's the description of this of this child, is this child needing help or not? And, and it's, I think it's a I think it's an I guess, it's still an ongoing, an ongoing discussion. So yeah.

Daphna 59:34

I have a question about major data sets also, since we're talking about, you know, research outcomes. And we alluded to this a little bit in in you know, the, the COVID pandemic has been awful, awful, awful. And I think in, in working around some of the restrictions, we've found ways you know, like to meet families where they are like more telemedicine. and things like things like that. And we may be able to reach some of our highest risk populations that we weren't able to reach before, which I think is definitely a benefit, especially when we're talking about long term follow up and developmental follow up after the NICU. But my question is related to those research outcomes, and especially in the major datasets, and what is your advice to people who are doing this sort of research in accounting for some of our societal structures that certainly impact development? You know, when you're looking at a specific therapy and the long term outcomes, you know, how, how do we separate out? How much is related to the therapy and how much is related to things that happen, you know, to children after they leave the NICU? That's, that's potentially out of our control, quote, unquote, as neonatologist, but not out of our control, theoretically, as a society.

Speaker 3 1:01:05

There's a lot to unpack in that question. Because I think in large, in large datasets, if you're thinking about it as data sets, but in, let's say, clinical populations, and in research populations, there are such site differences already. I mean, that's a major, you know, significant difference is one site versus another. I mean, this is true for almost any outcome you can look at. So, you know, even if you put everything together, if you were to look at individual sites, there's quite a bit of difference. And I would argue that there will be quite a bit of difference between sites and in California, probably between regions. It sets we're lucky to have again, in high risk infant follow up, which is in collaboration with our California Children's Services, we are able to look at Regions and even to some extent, counties, so there are probably going to be as we think about our analyses, you know, to come, you know, being able to identify enough information that might be during COVID, et cetera, or versus after COVID, for instance, if we ever get after a COVID, that's fair, there will, there will almost certainly be regional and site differences. But in the same way, you know, you say like some some, you know, services may not have been able to be offered. In some sites, I am very well aware that for it except for a very short period. services were doggedly offered continued to be doggedly offered in person, whether that be home visits, whether that be, you know, having a different setup in the institution, but doggedly offered, whereas others really shifted to, you know, telehealth. And the other point after that, and something that we're looking at, in California, is this issue of telehealth, you know, I mean, it seems like it would be the promise for, you know, leveling disparities, but in reality, it may not be the promise for leveling disparities, because what we have recognized both from from survey based questionnaires to the sites themselves and also from data that we are beginning to look at there. There are disparities in launching telehealth, in supporting telehealth at the institution. So, initially anyway, there were institutions that were launching telehealth for other clinics, but sort of high risk infant follow up was way down the pike, you know, in some institutions, and then there are some, there are some groups that are, you know, have said, Honestly, my patient population is not able to access that kind of bandwidth that's required for a real telehealth appointment. So we have to find a way to continue to do in person service and some of these sites specifically decided they're not even going to try to launch that, because they know from discussions with their patients, that that's not going to work for them. So I think it's going to be it's, it's going to take some more time, I think, to really realize what the impact of that is, but I completely agree with the concept that we need to be thinking of many different tools that we can use, you know, going forward. Yeah,

Ben 1:04:46

yeah, this is something that the workforce has realized right where they thought that remote work was going to be an equalizer, but then they realized that the person that doesn't have a large apartment or a large living space or doesn't have a good computer and a fast connection is going to be lagging. Behind the person who's, who has a nanny to take care of the kids or large office to work from and all the tools, right, so it's not it's it's interesting how we're figured finding out where where there's limitations to, to this to these new interfaces. Yeah. And

Speaker 3 1:05:16

I think I think you're right, I think, you know, even the, quote unquote, working from home, I think that they, you know, locked down was very enlightening as to, you know, going back to maybe even an early point that you guys made, that the, the responsibilities may fall unequally on some people for taking care of the entire family, you know, so it's very hard to be at home, taking care of homeschooling your two kids, while you you know, or, you know, your more than two kids while you're supposed to also be doing a full day's work. It's not a, you know, it's not a reasonable possibility. And again, I mean, I think there's a lot of mental health distress that has that has come from from this, from this period, you know,

Ben 1:06:18

my last question, because we're obviously running, we've went over time already, but that's okay. How do you what is your advice for young physicians who are struggling with the counseling of families when it comes to neurodevelopmental outcomes in balancing the data that has been published? And the what, what Daphna and I like to call the end of one paradox where parents are like, I'm not running the 6000 baby study, I have to beat I have one child that needs to beat your outcomes. And and the difficulty in, in both presenting accurate data, but also not I mean, it's not unreasonable that if you're right, if you're just betting on one child, because it's your son, your daughter, say, maybe maybe my child will beat your outcomes, and then I should remain hopeful. How do you? What is your advice on how to counsel families when it comes to that specific issue?

Speaker 3 1:07:13

That is also a very big question, then because if you know,

Ben 1:07:20

it, with these questions, these questions have to come at the end when everybody likes them.

Speaker 3 1:07:24

I think it also I think it also depends on exactly, you know, sort of what your your thought process is when you're, you know, where you are in the counseling, because you can counsel quote, unquote, in terms of sharing information, but you know, if you're counseling to, to be in partnership with a family about what the next steps are for their child, I think it always comes to trying to understand where the family is, as a first step, you know, what, you know, this is a very complicated one world you've been in, you know, whether this is prenatally or, or in the neonatal period, you know, and you've heard many things, you've met many people. What is it that you understand, not a test? What what do you understand, and sort of where are your goals, because if the goal is, you know, I, you know, again, in the in the fetal world, if the goal is I expect to have a child that has none of these problems that I've heard about, then you have a lot of work to do, to really sit down and speak with the family and to make sure that we, you know, maybe the goal is it is different, maybe the goal is, you know, restated, but you know, these are all families that have gone from probably expecting, you know, a full turn child in their arms in Mother Baby Unit and going home to a completely different world. And so I think we need to always start with what with the family, whatever the family is, and maybe it's speaking with the mother is the family about what they understand and their goals before we kind of get into numbers. Because just just talking about a litany of numbers is not going to be meaningful to that to that family. In most cases. In some cases, there are, you know, very detail oriented families, but even in that case, I think it's still important to kind of get a sense of where they are, what they understand and definitely, you know, what are their hopes and their goals and also acknowledge that they are grieving they're grieving the loss of what they expect it to be a normal outcome or a different outcome.

Daphna 1:10:10

Well, I'd love to sit in on one of your prenatal consults a personal passion for me. But my last question, as we're, again over time, and is for our trainees who are listening who are interested in this space who say, okay, I can see a future in studying longer term outcomes. What are things that, you know, are right for study that, you know, the holes, we still have the gaps in study?

Speaker 3 1:10:38

Yeah, I mean, I think we talked about some of them throughout this whole time that it's, you know, I mean, there's there is always, there is always space for longer, longer term outcomes. And I would say that is a huge part of what we need to think of some people talk about to your outcomes, his long term outcomes that makes me shudder, because that's not a long, long time. But, you know, what, what do these, you know, really continuing the process of looking at family, you know, how families are, are coping, how they are succeeding, and looking at maybe different different endpoints for later for later and also implementing? I think, another big opportunity that we talked about before is, is in thinking about and implementing different assessments. And, you know, really, maybe flipping the script a little bit on what is the what are the outcomes that we care about, even at two years. And that will, in depth, but that will definitely and already has led to taking paths, maybe toward public health interventions and, and broader advocacy and influences, which I think is always important for physicians, and especially for physician scientists to partake in.

Ben 1:12:08

That's, I think that's great. We can we can we can end there. Daphna. Thank you. Thank you for making the time. Dr. Susan, Susan, hence, thank you so much for making the time today to talk to us. This was phenomenal. I think there's a lot of highlights. And yeah, I think I think we're gonna we're gonna get great feedback from this episode. We get any bad feedback from any episode, but this was particularly Excellent. Thank you. Thank you so much. And we'll have resources linked to the episode page for anybody interested in your work and the things you're working on. So be sure to check that out.

Speaker 3 1:12:45

Thank you. It was a real honor to be a part of this conversation. I'm really I learned a lot from both of you. Thank you,

Unknown Speaker 1:12:54

honors, ours honors ours. Thank you so much.

Ben 1:12:57

Thank you. Thank you for listening to the incubator podcast. 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 NICU You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot d dash 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 professional. Thank you

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