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#131 - Dr. Satyan Lakshminrusimha MD


Satyan Incubator Podcast

Hello Friends 👋


We have the privilege of hosting on this week's episode of the incubator podcast the talented Dr. Satyan Lakshminrusimha. This interview was one that Daphna and I eagerly wanted to record, and many of you stopped us at conferences around the country to ask: When are you going to interview Satyan? Well, this podcast is here, the time is now, we hope you enjoy this episode with a true leader of our field. A physician that embodies courage with humility.

Enjoy!

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Please find below some of the articles that were mentioned in today's episode:

Lakshminrusimha S, Murin S, Lubarsky DA.J Pediatr. 2023 Apr;255:1-6. doi: 10.1016/j.jpeds.2023.01.013. Epub 2023 Jan 31.PMID: 36731717 No abstract available.


Lakshminrusimha S, Olsen SL, Lubarsky DA.J Perinatol. 2022 May;42(5):683-688. doi: 10.1038/s41372-022-01370-0. Epub 2022 Mar 22.PMID: 35318428 Free PMC article. Review.


Mercurio MR.J Perinatol. 2021 Oct;41(10):2561-2563. doi: 10.1038/s41372-021-01192-6. Epub 2021 Sep 1.PMID: 34471217 Review.

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

Ben 0:54

Welcome. Hello, everybody. Welcome back to the incubator podcast. It is Sunday. We're doing well Daphna. How are you?


Unknown Speaker 1:06

I'm doing great. Thank you for asking. How are you doing?


Ben 1:08

I'm POST call today fish. I mean, yeah, we're recording not live. But by the time this is recording, I'll be postcard. So. Yeah, that's right. It's a postcard week. I feel like I'm postcard everyday this week. But no, everything is good. We are very excited about today's interview. This is something that people have been waiting for, I think. But yeah, I mean, in terms of incubator announcements, I just wanted to go through a few things. Before we kicked off the interview. We had our incubator webinar on Monday, May 29. It was it was great. It was it was was good to connect with the audience that you ended up, we ended up streaming it live on YouTube. We'll have another one on Monday, Jun 12, at 8pm. US Eastern time, you can RSVP and register for the webinar through our website. And we'll try to stream that again on YouTube as well. What else we are releasing some of the we're really going to try to develop our YouTube channel. And we're going to develop this by actually starting to post this week. We're actually by the time this episode is aired, we have released already to two of the of the Delphi talks. And the TEDx conferences from from our come from our conference have been submitted to the TEDx team. And so there's a little bit of a review process, I think, but these should be up on the TEDx website pretty soon. Yeah, we're very excited about that. So start checking those out. And this is what's giving us the strength to plan for Delphi 2020 These are the things that I wanted to mention anything else stuff? No, no, I


Unknown Speaker 2:56

think you got it.


Ben 2:58

So without spending much more time on on on admin stuff we're going to introduce our guests for today, it is none other than Dr. Satin Lakshman ritsema. And he is the Nancy and Dennis marks Chair of Pediatrics and the pediatrician in Chief of the UC Davis Children's Hospital, is primary focus is how fetal lungs change at birth to breathe air and disorders of transition, specifically asphyxia and persistent pulmonary hypertension of the newborn. He is funded by the NIH to evaluate optimal oxygenation in the lung injury and PPHN. He is the PAI of the multicenter trial evaluating mirror unknown in Congenital Diaphragmatic Hernia. He's also the CO editor of the textbook essentials of neonatal ventilation by published by Elsevier. Sutton also enjoys drawing medical illustration, which we'll talk to him about and has published more than 270 peer reviewed articles and 500 illustrations in pediatrics and neonatology textbooks, journal articles and apps. Yeah, no, he's an incredible, incredible man, incredible physician. We are very excited to have him on please join us in welcoming to the show. I'm going to try his last name one more time for Dr. SACHIN Lakshmi received such an Lakshman receive. I thank you so much for being on the podcast with us this morning.


Speaker 3 4:27

Thank you, Ben. Thank you, Daphna for both, both of you for inviting me here. And then special thanks to you for pronouncing my last name. Right, which never happens. By the way.


Ben 4:37

I did prepare, and I'm going to be very upfront. I did it once I did it right. I'm probably not going to try again the rest of the lives. We have to be we have to keep pace today. Definitely. Because Satyen has an extensive portfolio as they say in the business world. And there's a lot of us there's a lot of things for us to cover too. A and, and I think I wanted to maybe start off with a subject that is that is not really super pleasant for a lot of us and something that you've published about very recently, which really involves the business of neonatology. And


Unknown Speaker 5:16

you're diving right into writing.


Ben 5:20

And, and I'm very interested in your perspective, because I think it is not often that we have physicians, such as yourself that have this, number one, this wisdom of experience, where you've been in this field long enough to actually have seen it change, you also have this ability to have an over arching view of where we are, where we are going. And some of the some of the things that you are mentioning in some of these articles are quite frightening for how we will fare as a profession and how our patients are the care that our patients are going to receive. You are referencing in one of these articles. Another perspective written by Dr. Mark mercurial, were talking about this RVU to FTE ratio, which I'm going to let you explain and, and calling this a race to the bottom. And I think I think this is really where we are now, do you want to tell us a little bit about why you were interested in in really touching on a very thorny subject, and what are the things that jumped at you that that we need to be aware of?


Speaker 3 6:24

That's a great start, then, let me give you a bit of my history into the business aspect of Pediatrics in general. Once I finished my fellowship, as many of you know, I came here from India on a j one visa and had to work as a pediatrician in a health physician shortage area in a town called Pueblo in Colorado. And when I was working as a solo pediatrician, I realized the importance of worker views and the critical role that neonatology plays in these business aspects of Pediatrics, the number of worker views and money that I would generate, by sitting in the office and seeing patients all day was roughly equivalent to the amount of money I would generate, had I gone to the delivery room, and integrated the baby, every time baby managed the baby for a couple of hours and then ship the baby out to their tertiary center. So then I realized the importance of work, how we use and the crucial role, neonatology plays in maintaining the worker view load and the burden of the Department of Pediatrics. Subsequent to that, I went back to Buffalo, became a lab rat and was on the guard my clients and dedicated my time to research. And all of a sudden, one day, my chief return comes to me and tells me that she's taking a job as a chair, and she wants me to consider moving in as an interim chief. And to cut the story short, I took on the job and went through 12 months of what I call a chief shock, which from which it was tough to recover, because understanding the business aspect of neonatology was quite difficult. So the bottom line is that pediatrics is paid at a very low rate in this country, mainly because of the fact that Medicaid reimbursement varies from state to state, and is significantly lower than Medicare reimbursement, and of course, considerably lower than commercial reimbursement. The way business works is that you negotiate and negotiate with insurance companies, for every cent value given to a given work RVU. And that's how business of medicine works. And that value can vary for anywhere from $30 to $100, based on the insurance that you're talking about. So even a small difference between Medicaid payments and Medicare payments and commercial payments has a huge impact on pediatrics in general and neonatology in particular, given the fact that over 50% of births in this country, predominantly are born to mothers who have Medicaid. So that's the bottom line that drives these low salaries. So with that being said, neonatology is in a unique situation, at least for example, when I was a fellow or a junior faculty member, we used to round on anywhere from 30 to 60 babies because all we had to do was round. And the residents would have written some beautiful notes, and we would either just sign them and that was about it. And then billing would happen. And after finishing rounds, I had a chance to go back to my lab and do my lab work when I was on service. And then I would be on night call come and get a sign out and then subsequently, I would go home and the fellows and residents would manage the show and maybe once in five or six nights I had to come back in briefly to take care of some emergencies and that's how it worked. And with such a model, academic neonatology developed a an ability to do innervate a large number of workout views. And just to give you an example, an academic neonatologist right now based on benchmarks generates anywhere from 11,500 to 11,800 work RV use per year, or 1.0 FTE. This number doesn't mean much when you just look at it, but of the 151 sub specialties that are listed in various medical databases, including the AAMC, which is the American Association of Medical Colleges, or CPSC. If these clinical practices solutions section, these agencies of this 151 specialties, we are somewhere in the top four or five sub specialties that generate worker we use we are one of the top or curvier producing specialties, but when we look at salaries, we are down somewhere at the bottom. And that's the discrepancy that that's what I call this neonatology paradox. So this is what got me interested. And I started welding more and more deeply as a chief of neonatology, and subsequently as a Chair of Pediatrics. And right now I serve as a co chair of the front row system for UC Davis, which has given me a much more deeper understanding of how pediatric Crohn's and academic pediatrics in the business of pediatric runs. And there is a lot of cause for concern as to how this model will sustain moving forward.


Ben 11:29

And I think for me, I remember when I was a fellow, I had no idea, I think, the ACGME and the training programs are doing a very good job at protecting fellows from all this nonsense of RVU fts. So I just want to take one second to just make sure that we bring everybody up to speed when RVU is a relative value unit, which is basically the work you're doing in the NICU as compared to the kind of reimbursement generates, and then an FTE is a full time equivalent, which is the amount of physicians that are time the the amount of time that our physicians are hired to do a certain job. And in the in the article, you do mention this RVU to FTE ratio, which is how much can we actually be productive when it comes to the neonatology or medicine in general, as compared to the number of FTEs that we have available. And so ideally, hospitals and hospital administration would like the RVU to f t ratio to be as high as possible, meaning you're generating a lot of income for the hospital with the fewest possible number of physicians. And in the article, you mentioned that this paradigm is actually reinforcing the physicians. It is reinforcing a behavior where physicians are incentivized to spend less time with patients. And can you talk a little bit about how that works?


Speaker 3 12:59

Ben, thank you for outlining the definitions. As you rightly mentioned, a relative value unit or RVU, is something that allows us to compare work done by one subspecialty to another, for example, somebody seeing a patient in the office, for example, Gen X two or car views per visit. And unit all just taking care of a patient, a really sick patient in the delivery room, and managing the patient for 24 hours generate something like 18 recap videos. So this is a way to compare different subspecialties across the age spectrum from OB all the way to geriatrics. So that has led to these benchmark development and I am guilty as the chair of doing exactly what you said I do incentivize my my colleagues in the department for exceeding their benchmark. So I am perfectly guilty, absolutely guilty of creating a competition where producing more worker views is rewarded. This has two important negative effects one ear by ear. Because of this competition, people tend to produce more and more worker views. And that just increases the benchmark gradually. So in other words, you tender to 10,000 this year, I would like you to produce 10,500 Since everybody produced 10,500, the benchmark moves to 10,500 the next year. So again, there's a rat race and you generate more work RVU. So this is a vicious cycle that artificially increases the work RVU benchmark year to year and creates an internal competition and which is which is very unfair. The second is the point that you mentioned, which was very elegantly brought out by Mark Mercuria in his article titled the race to bottom and this basically says that in a given day, there are only a finite number of hours for a neonatologist. So when you I come to my administrators and tell them that, hey, I increase my worker productivity this year by 10%. In essence, what it means that it what it means is that I spend 10% less time with my patients on a daily basis. That's exactly what it is because the number of hours I work is kind of finite. And the number of patients I have is also fairly limited. If I'm generating more or car views, I'm taking care of more patients than usual, or doing more procedures than usual. In essence, I'm spending less time so I don't think we should take pride in the fact that we spent less time with our patients, especially young mothers who have delivered a sick infants, they would love to talk to an electrologist as much as they can. And the main aspect of attending unit of this job is to explain and alleviate the tension and stress that the mother and father are going through. And in essence, by generating more work out of us, we are spending less time talking to parents, and we are minimizing on what we really should be doing. And that's the second negative aspect of this rat race for us.


Ben 16:05

Yeah, because we're incentivized to see as many patients as possible, make that counseling session as quick as possible. So you can get to the next one, instead of being rewarded for taking the time to sit down and going over all the different details. Absolutely


Unknown Speaker 16:16

correct. Yes.


Daphna 16:19

So you've alluded to the fact that this kind of RVU infrastructure, we're, you know, it creates this system where we're always trying to meet new goals, right? And the goal is the goalpost is changing. So, is there an optimal RVU? Like, what's the break point where we can keep systems happy, but we can still provide good kind of value based care where the patients are happy, and the physicians are happy and the system is happy? Is there? Is there an optimal RVU?


Speaker 3 16:57

Definitely, I wish I had an easy answer to your question, you brought out a couple of very important topics. The first one is value based management of patients. I think, as the health system us is really struggling to come up with how to incentivize value based care. So the way the hospital gets paid differs from state to state. In some states, they use what is called as the APR DRG method, where if you're admitted candy for weaker who based 100 grams is the X number of dollars that you get, if the patient does phenomenally well and goes home in 50 days, you make money out of it, if the patient gets sick and stays for 150 days, then you lose money on it. And that's one way the hospital gets paid. In some states, the hospitals just just get paid based on daily revenue, the longer they stay, the more incentivized the hospital is to keep that patient so. So there's a lot of variation in that between state to state. For the most part, physicians are paid on a daily basis. So whether you code for a critical care or an intensive care or a daily hospital stay, you get paid based on that. And this also creates a bit of a discrepancy between what is happening from a recovery productivity perspective, and from a hospital revenue perspective. Setting that aside, we really need to develop a value based system where quality of work is incentivized more than quantity of work. And we are not there yet. And every health system is struggling to come up with a optimal way of rewarding that. And in my humble opinion, I think we are at least five to 10 years away from establishing a very well established, value based incentivizing system. So in the meantime, I would really love to see worker views going away as a benchmark, because we need to move on into what is called as a staffing model where you basically look at a given NICU, see how many number of hours you need to run the NICU, and then come up with an optimal definition of clinical FTE in terms of hours per year, divide the first number by the second number and say this unit requires 10 neonatologist around this and then provide 10 unit charges and not worry about what what kind of use they produce and focus more on quality of care. But that system runs into one major issue. That is they get paid based on what kind of use and for all of us to survive and make a living. The Department of Pediatrics needs to get paid or the non academic settings or whoever is running, the business needs to get paid. And that payment always comes in the worker view using our current methodology and that's where the current crisis exists. So what can we do to get away from this? I think the way the benchmarks are devised is pretty flawed in my opinion. And there are two reasons Why I worry about the current methodology? One is that in most academic settings and possibly in some non academic settings as well, they take your FTE for example, I am a Chair of Pediatrics and my clinical FTE is only 0.2. And then that take the number of workers I produce and being a chair, I don't take night calls, I only do daytime service, which is the highest worker regenerating aspect of neonatology. And so if I do four to five weeks of service, the take the number of workers and generating and multiply that by five because I'm a point two FTE person, and then report that number to all the benchmarking organizations as to watch with the definition of 1.2 FTE, which is absolutely unfair for a neonatologist, who's working days and nights and doing clinics etc. And these aspects of nighttime call, and clinics really don't generate a lot of work or videos. So I think the first recommendation that we should probably look into is that number of physicians who contribute to this work RVU benchmark should be lower and only include physicians who are working more than a certain clinical FTE typically point two five or point three FTE. And once that's done, that will naturally bring down our career benchmarks in Unit ology. To get to the bottom of your question, I personally feel that a number somewhere around 8000 worker views per year is reasonable for neonatology. But that's already at 30 to 34% cut from where we currently are, and that's pretty drastic. And it it will take us if not be achievable at the current time. I was hopeful that during COVID, the word carrier benchmarks on unit ology ran down a bit. But my bubble was burst when I saw immediately in the Porsche COVID. year for 2022, all the numbers went back up again, suggesting that we are back in our race to the bottom, and nothing has really changed.


Ben 22:09

I think we're really getting into very fine details when it comes to the to these are views and so on and so forth. And I wanted to then jump on that and then ask the question based on what you're describing, which is that the NICU is a very profitable unit for the hospital when you have a very nice paper published in the Journal of Pediatrics in the journal paleontology that discuss these things. And in there, you do mention how, how how much our views the NICU as a unit produces for the hospital. And yet, there is still that age old problem of poor reimbursement for pediatric care. Why is it that no one values the care being given to children as much as the one being provided to adults? Why is that? How bad is this problem? And why is this still an issue?


Speaker 3 23:00

It's a major issue. The way I explained this to my residents is that directors should be based on patient's body weight, not the compensation for the caretaker. There is no reason why somebody providing genital intensive care should be paid lower than somebody paid conducting surgical intensive care or medical intensive care. I think all these salaries should be compatible. In fact, when you look at the size of the units in major hospitals, often the NICU is the largest ICU in various health systems. So it's unusual to see a 60 7080 bed MICU. But it's very common to see a 8090 even 100 Bed NICU. So an ICU is generate a lot of revenue for the hospital and really critical for functioning of children's hospitals. And I can tell you for sure that none of the children's hospitals in this country would have survived the COVID pandemic, especially 2020 and 2021. When pretty much RSV was gone, and there were no patients on the floor, and the only unit that was full and running was the NICU and without NICUs none of academic pediatric departments or children's hospitals would have survived. So the NICU is really vital to the business aspect not only on the professional side, but also on the hospital side. This is true for both academic and non academic neonatologist, by the way, so because non academic unit all this work in various types of settings, including large level four units and some community level hospitals and all these units. NICU does contribute to a significant revenue for supporting these units in two ways. One, the NICU generates revenue by itself and to the presence of a NICU enhances the OB practice and MFM practice so mothers come to deliver. And many as many of us know, the chief person who decides where someone from a family goes to to get care is the mother And if she had a good experience delivering her baby and with the care of her baby, she, of course will recommend that hospital to every single person in her family and bring other family members to the same hospital. So. So providing OB care is a big, big critical thing to enhance business of any hospital in this country. Going back to your second question, I think the crucial factor is one is Medicaid that we already talked about the low Medicaid reimbursement. The second issue is that caring for a pediatric patient is a lot more complex than caring for an adult patient. When I go to my own doctor for my own care, I don't spend more than five minutes. I mean, he comes in checks my blood pressure tells me this and that, and then tells me what medications I need to take. And then I'm out. On the other hand, when I take my son or my daughter, or if you go in there, then I have like 1000 questions to ask the pediatrician. And then once I'm done asking, then my wife starts with her list of questions. So caring for a pediatric patient of any age group for that matter, is basically taken care of three pupil. So this is what we call us indirect care, you're not providing direct care, you're fighting indirect care, you're spending x amount of time caring for the patient, but to X amount of time addressing questions from the parents, and in some cases, even grandparents. So this tends to reduce a pediatricians ability to see more patients, for example, an internist can see one patient every 10 to 15 minutes, but a pediatrician needs anywhere from 15 to 30 minutes to care for a patient because of this reason, plus, we are an evolving field, nothing much changes between when you are 25. And then when you are 65. On the other hand, so much changes from the day you are born to the time you get to 21 that pediatrics is such an evolving exciting and dynamic field, that every single visit is so important that you need to spend more time with with children and their caretakers. So that limits the number of patients that you see. And that also reduces the number of worker views you generate. My personal bias here is that at some point, I really feel that Congress should pass a law saying that every child less than 21 years of age, when they are taken care of by a caretaker, they should automatically multiply the workout we use by 33%. To take into account the fact that it takes longer to care for a child than to take for an take a take care for an orphan adult. So there should be some kind of a pediatric incentivization with what car we use, so that we are paid on par with the amount of time it takes to see these patients. Believe me, pediatricians are not lazy, we work very hard. And we chose pediatrics, not because of the money we make in pediatrics and because we love children. And we truly believe that children are the future of this country. And so if Congress and administrators and politicians believe in that principle, they should come up with guidelines where reimbursement for pediatrics is enhanced, so that more and more medical personnel or medical students go into the pediatric residency field. But I'm really worried as to how that looks at this time, because I'm worried that that the future of Pediatrics does not look very bright unless reimbursement gets better. As a as a as a Chair of Pediatrics, many medical students come to me for career counseling when they decide to choose pediatrics. And I was never for I've been in this field for almost 30 years now has never before. I've never get a question from a medical student asking, What will salaries look like? But now that's the number one question that asked what the salaries of pediatricians look like, because everybody is coming out with a huge loan, and they want to know how to repay that loan. And if reimbursement as a specialty in pediatrics is low, it makes repayment of these loans very challenging.


Daphna 28:59

Do you think that pediatricians Being the nice people that we are have played a role in like letting this happen? That's one question. And two. What's our role now to go to our administrators to go to our legislators to say I mean, this is not sustainable.


Speaker 3 29:23

I think we are absolutely guilty of the first thing you mentioned that. In fact, many people assume that pediatricians are very nice, humble people who don't demand much, and that's the wrong impression that we have developed. And so I think that needs to end we need to demand what is right for us, not because of any selfish motive, but because the future of children is dependent on paediatric workforce and without enhancing and supporting the people The attic workforce, children won't really do well in this country. We are all very well aware of the mental health crisis that's going on among children. I mean, when you look at all these violent events that are happening around the country, it's it's disheartening heartbreaking to notice that not only are the victims in many cases, children, but in many cases, the perpetrators are also children, which is really heartbreaking to notice. So addressing mental health among children is really important. And given everything that's happening in this country, there should be more focused on pediatrics, pediatric care, so we should negotiate better, we should work better with our administrators and politicians, and demand what is rightfully ours, which is an appropriate pay for what we do. It's, it's unbecoming to see a pediatrician who has gone through four years of medical school, three years of residency, and three more years of fellowship, get started on a salary, which is lower than what a graduate would make by walking into Apple. How does that make sense? That never that doesn't make sense at all. And what is even more heartbreaking is that there are five sub specialties in pediatrics, which get paid less than a general pediatrician. Why would somebody go into three more years of fellowship if the salary is going to go down? None of this makes sense. I think we really need to come up with a better way of reimbursing pediatricians to make sure that our workforce is sustained, and more and more people find this to be an enticing and exciting field to go into.


Ben 31:36

This episode is proudly sponsored by red meat Johnson recognized 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 johnson.com. So in in these articles, you mentioned physician morale and well being you're touching on this subject. And I think I want to be a bit facetious here. And I think as neonatologist, we can say, well, so what so you work with more you see bit more patients big deal. Like we're tough, we're good. We're intensive care physicians out this whole RVU to FTE ratio. Yeah, I'll see the 15 patients today. It's no big deal. But I think it's, it's sometimes it gets confused, that we're not really asking how many patients can you see in a day because I think many people will gladly enter that competition and try to see how many they can see. But I think it's more than that, because it involves more of the prolonged stress that is applied on the workforce. And also, as you mentioned, the expectation that our viewers are going to go up every year, right? I mean, every year, you're going to do more somehow, even though that doesn't translate societally in terms of the number of births the number of like, exactly how far can we push this to expect higher revenues every year? Can you talk a little bit about what physician moral distress and, and and focusing on wellbeing looks like for physicians as we are subjected in the workforce to these expectations.


Speaker 3 33:09

A lot of things have changed. In the field of neonatology in particular over the last 2025 years that I've been in, I joined my fellowship in 1996. And so much has changed how much has changed in neonatology that it's really hard to fathom. And every single one of these changes has had impact on our ability to function well, and also our own well being and work life balance. Just take, for example, electronic medical records. When it came through, we all assumed that oh, this would make our life so easy. And that's exactly the opposite of what has happened. And hopefully, AI will bring in some new innovations that will make our life better. But before that happens right now, it's much easier to write a note with by hand and figured out how to do this in epic, or Cerner or whatever else you use. There are some benefits don't get me wrong, but at the same token, it has not made our work life balance any better for sure. The second challenge is that the pediatric workforce that is coming in, is moving farther and farther away from critical care. So as many of you, as many of our we all have heard ACGME has proposed new changes to the resident curriculum and the ICU care it now it's recommended that all ICU care during residency to be live to be around 12 weeks approximately. And it is theoretically it's possible that there might be a pediatric resident that just does four weeks of NICU rotation and comes and graduates and it's out in the field. I'm not blaming ACGME here because they're addressing the mental health crisis that's happening among children and adolescents which is a very important field but at the same token, this is not addressing what is really needed in a rural area or a non urban area, where a pediatrician has to take care of everything, go to the delivery room address issues there and then take care of all the children etc. So I think we are not addressing that issue. But in essence, what this is creating is that a 30 year resident, quite often is not comfortable going to the delivery room by himself or herself, because they're worried about their abilities. So the incoming fellows are much more ill equipped to deal with neonatal intensive care than before, and that puts a bigger burden on the neonatologist to train them, and you need a lot more hands on experience. The second thing that has been that has changed is that the acuity of neonates in the unit has gradually gone up. And that has resulted in our need to stay in house at night. And that has had a huge impact on work life balance, staying power hours shift during the day, and then covering a night really makes you tired and exhausted and tends to have an impact on your work life balance. And that has a huge negative impact on how well being can be perceived. The third thing which is a very welcome shift, in my opinion, is that increasing number of neonatologist are women right now, when I was a fellow it was a, I think a 5545 split between male and female fellows. And now, if you look at the recent graduating batch, the American Board of Pediatrics website I think 74 or 75% of graduating neonatologist are women right now. And COVID showed us that women are disproportionately take a lot of burden at home on the and especially a daycare and things like that, and the lack of daycare during COVID such a sad such an uneven burden on women in this country. And that really made it clear to us that we need to come up with better ways of creating work life balance in the NICU.


Ben 37:15

I wanted to jump on one thing that you said sorry Daphna, because you mentioned the promises of EMR and how we thought this was going to make things better. And it turns it, for many of us, it feels like it made life worse. And I have the same ambivalence today towards artificial intelligence, right, I think I am fascinated by innovation, I'm fascinated by chat GPT and all these new AI tools. And on the one hand, I have a feeling that these tools can really help us deliver care in the NICU at at scale and not today. But I think in in the next few years, however, I also see the dark side of this where if we are seeing in neonatology the increase in productivity that other spaces are seeing, then it's not going to be it's not going to be sufficient for us to then go back to the bedside and then spend another 10 minutes explaining something to a parent, then the hospital is gonna say, Well, now that you can actually complete these nodes much faster with AI support, we're going to expect you to do twice the amount that I feel like this is going to just end up raising the bar. Do you think? Do you think where do you stand on that? I'm just curious as to do you see AI as a promise? Or do you see the AI as a sort of Sword of Damocles that's just dangling over our heads right now.


Speaker 3 38:25

Well, I'm equally worried about what AI will do to us. I share your concern, then, at the same token, I'm an optimist. And I'm hoping that reducing the time I'm sitting in front of a computer to write my notes will increase the amount of time I can sit at the bedside and talk to your parent or spend time with a patient and examining or teaching or other aspects of care that really made me go into the medical field. I definitely did not go to become an intelligence to write EMR notes, I can tell you that for sure. And I'm sure none of us did. So I'm hoping that more efficient notes writing and documentation and ordering will enable us to spend more time with with patients. I think it's up to us to draw a line and tell administrators that expecting higher productivity because of AI is not practical and should not be even entertained. I think a line should be drawn there so that no further increase in productivity should be expected because of new methodologies such as AI coming into the medical field.


Daphna 39:36

Well, I wanted to talk about something else that you touched on and and you've written about, you've spoken about to you know, standing room only crowds and I think when we talked about work life balance and the changing workforce, and it's really about this discussion to do we have to reevaluate the staffing models. I'm hoping you'll I'll speak a little bit to that.


Speaker 3 40:02

Yeah. So there are two aspects to economics in neonatology one is how much do you work? And how much do you get paid? So this is basically the bottom line of it. We talked about compensation already. The next thing to address is how much do we work? I truly believe that once you're in house, every bit of work is the same, it should be valued in a fairly similar fashion. Obviously, if you're doing high intensity work, that should be rewarded better. But at the same token, work is work, you're staying away from home, you're staying away from other things, and you're doing things in the hospital. So my definition of an academic product to work here is a unusual number, it's 1656 hours per year is the way I see it, that's a number that I use a lot in, in my own department. Where does this number come from? This is approximately a pediatrician, doing eight clinics a week for 46 weeks a year. So that's where the math comes from. And so if you do the math of four hours of face to face time, and 30 minutes for documentation, you multiply all this and you'll end up with this with this number. I personally feel that we should do away from other methods of calculating FTE, and come up with an hour based method because that's easy to compare between specialties. It's easy to compare between institutions. And that number is something that I would like to promote for the definition of a clinical FTE for all fields, I'm not just talking about your mentality, in terms of neonatology that comes to, you can eat credit in any way you want. And one formula that I use is that if you're not staying in house at night, the credit given is somewhere between 25 to 50% of a full hour credit. And other than that, if you're staying in house doing whatever you're doing, then the credit is the same, and then you calculate the number of hours you work using that formula. This applies both academic and non academic neonatologist. And I think I think that's the way to standardize things. The second important factor here is transparency. I think the days of the chief or the chair telling you how much you should work or they're gone. I think there should be a transparent model that's visible to every single faculty member in an academic department and every single neonatologist in a non academic setting, clearly stating, This is the formula that we use to define FTE, this is what your FTE is, and this is how many hours you're working per year, and that should be transferred between all people who are working and maintaining Transparency is key to gaining trust. And if you don't have trust, then you won't have wellbeing. The last point I want to make is that there's a thing called a dipole phenomenon in physician wellbeing. For some reason people who take care of patients at extremes of age are invariably happy among all the pediatricians neonatologists are some of the happiest people. And similarly, among all other medical subspecialties, geriatrics are the happiest people. So this is going to take care of patients wearing diapers, I think you get much more fulfillment for the work you do and you tend to be happy. That's good for neonatology. At the same token, we should not be taken advantage of by other specialties. We need to stand up for ourselves and then be emphatic about work we should be doing and clearly define our work goals and have clear cut and transparent work RVU requirements and FDA requirements in terms of hours per year.


Daphna 43:38

I love that I am I know the range is quite broad, but you've you've done the work and all of the math. So what is the typical, you know, hourly work look like for our colleagues kind of nationally, compared to the benchmark that you're setting.


Speaker 3 43:58

It varies quite a bit. Recently, there was a white paper that was published by the American Medical Schools department of chairs committee, the unstack and it shows such a wide variation in the number of hours that neonatology works, it's almost like a fourfold variation. But the bottom line is that if you take academic neonatologist who are working more than 80% FTE, the average number of hours is approximately somewhere in the range that I mentioned 1600 to 1700 in that range. So I think that's the number that we need to promote and support and make it like an official definition for a clinical FTE are the numbers on the non academic slide are slightly higher. But I think they're not too far off.


Ben 44:52

I wanted to then I think we've we've, we've talked about staffing. I wanted to talk a little bit about some of the other things that you're focusing on and and Specifically, I wanted to talk about your illustrations which have literally made you famous. I mean, they're everywhere everybody's utilizing them. I think they provide a great resource for explaining things, both during lecture I've seen them use in every context, both by our colleagues during lectures to explain a concept, or by our colleagues, to parents to explain a concept. Is it true that you wanted to be a comic book? Yes.


Speaker 3 45:27

I'm much older than both of us. So I didn't have video games when I was growing up. So I grew up reading comics by various famous artist. And as you know, I'm from South India. So the three comics that had profound influence on my life were a little known daily paper strip called as Phantom. I'm not sure many of you have even seen it. It's a precursor of Batman. And every single newspaper sandesh trip has a script on it. And the second one was a is a European comic called Tintin. There's a famous movie by Steven Spielberg on it so that that was my second one. And the third is an Indian book called Chanda mama, which means the moon. It's a it's a short book that comes out every month with stories with children. So all these three had famous illustrators. sigh very harsh, and a guy called Sanchar. So these three people, I used to emulate their pictures and I really wanted to be a comic art in Illustrator for comics in when I was growing up, but my parents said, no, nothing doing this will not pay you for a living and sent me to medical school. So I tell my father that this is my revenge against what he did for me, too. Make my life going. I also want to credit my longtime mentor Robin Steinhardt, who many of you know, she's a woman in neonatology. She was my first attending on my first call as a neonatal fellow. And in one of my journal clubs, I had drawn a picture of a pulmonary vascular family vasculature with an endothelial cell and a smooth muscle cell as to how it evolves and neonatal phase, a fetal period to neonatal period. And she and her husband, David Stein, on this can that image and published it in a article and that was my first feature to be published. And I was more product that my figure was published more than that my paper was what made me really get into this field was that when I was doing my waiver job as a pediatrician, pediatrics is a very enticing field. You know, you work with children, they come and hug you, you walk into the mall, and they're running around and they see a doctor setting and they come and hug us. It's a very interesting field, I always thought I would not come back to academics. And one day, one of my nurses in the NICU, brings out one of her nursing books and opens it and says, Hey, I saw your name here. And then I realized that the same figure that Robin had scanned, was published in that textbook, and my name was written there. And I said, Oh, no, I'm going back to academics, I need to draw more. And subsequently, some of my mentees, provincials shaker, shaken woodwinds, now with have published an app and, and have really helped me promote my fingers. That's my stress buster, on a heartbeat hard day, when I'm stressed, I go back home, open my iPad and start drawing a picture. And that makes me feel much better.


Ben 48:37

Very cool. How long does one of these illustrations take you to draw? Usually? I know, I know, some of them. Some of them are. I mean, I've seen your work. So some of them are much more complex than others. So I know there's probably a range there. But on average, like how much time does it take you? It takes


Speaker 3 48:51

me one weekend to try a few years, maybe like around six to eight hours. But the good thing with with I use Adobe Illustrator from a figures, I could think is that you can use the same outline for different settings, you can make the baby blue, we can make the Navy pink. So


Ben 49:08

once you have it in, we use some of the things Yeah,


Speaker 3 49:11

modification makes it a lot more easier. And I'm not a good artist from a, from a art perspective. I take more pride in creating a concept and showing a concept and that's what I really want to get into that. I'm so proud to see many more neonatologist becoming illustrators right now I know at least six or seven of them. And I feel like a proud parent when I see them. And I really try to promote them as well every time they draw and post on Twitter or somewhere else.


Ben 49:45

But let me let me ask you this because I think that's a very important point you're making. We have maybe now a bit more than before, but we don't tend to ask our colleagues what else they're good at. Right? There's we all have these hidden talents and we use zoom wrongfully so that they are incompatible with the job we're doing. Whether you are a musician on the side, whether you are an artist, whatever it is, and then suddenly do what do you think we can do to try to get the most of out of out of our colleagues, the ones who are like I just said, like, like you who, who have a passion for art, and who suddenly Can, can combine both can combine both of your talents to then make your work product even more meaningful. Do you think? Yeah, I mean, do you agree with that?


Speaker 3 50:32

No, I think there is no difference between art and science. Medicine is a combination of science and art. And art component is often ignored and forgotten. If you're a talented writer, write something about non scientific aspects of medicine, there is so much to write about. If you can sing well, nothing prevents you from picking up a baby who is going to a narcotic often syndrome, picking their baby and singing a song to their baby that will calm the baby down. And I can guarantee you, the nurses will be very happy with you also. So use every bit of the talent that you have to promote various aspects of medicine. And the beauty of neonatology is that it's such a versatile field, that any talent that you have, any art talent that you have, can be somehow incorporated into this field, there are no limits to that at all. So. So integrating work life balance also includes into bringing science and art together in medicine. And there's a general rule that I believe Google follows that of all the work that you do, you should really enjoy 20% of the time doing what you really feel passionate about. And integrating art into science in the field of neonatology will enable you to achieve that.


Ben 51:47

Yeah, I mean, this is, yeah, I could not agree with you more, I think people have to try to find ways to incorporate their side talents into the work that they do, because there's always a way. And we are one of the examples. I mean, my two younger brothers were playing music. And so I learned how to edit their audio. And that's how to me going into podcasting became such a low friction entry point that I'm like, I know, I know how to do an audio edit. And that was it. And so I think, if you have to anybody listening, if you have something that you'd like to do on the side, there's a way to apply it to neonatology into your into your work. And that's always super cool. When those things come together.


Daphna 52:24

No, I was gonna say my associated question is, I think a lot of us from a very early age, like once we show this interest in science or math, we're driven away from the humanities, even if it's something we really enjoy, or for some of us are really good at not me, but some of and I wonder if that's a loss for the medical community to be driven so early on away from the humanities. And I wonder if there's a way we can start to reincorporate some of those things in medical training?


Speaker 3 53:02

No, I completely agree with you. I came from a health system. And an educational system in India, which is very much along the British system, where you basically finish your plus two and walk into medical school. I've, when I look at my children, my daughter is in medical school right now. And when I see that she spent four years doing something totally different, and then got into medicine. She's a much more complete person who knows many other fields, and has gone into medicine at a much more mature stage than I ever did. And so I think I think there's definitely a difference. And we need to bring humanities back into humanities and art both back into the field of medicine. Yeah, so I think that's really critical that will make I enjoy reading things like the peace of mind, etc, that came out in JAMA, where it talks about other aspects of medicine as well, in addition to just science.


Daphna 54:03

Well, we've talked a lot I mean, about the work that you do as a chair with your illustrations, and yet somehow at you your breadth of research is, is enormous. And so how, how do you how do you manage? I think we're all trying to decide like, how do we manage either being very specialized in our work or being very broad in our work? And how do you get it all done?


Speaker 3 54:32

I in on this aspect, I give complete credit to my family, my wife and my kids have been so supportive of my career. When I write something, I can show it to one of them and they can critique it and they helped me out that way. I'm gonna draw a figure they come and say, Oh, this color is not right. And they helped me fine tune it so. So I come to liquidate my family to in my ability to achieve what I do. I also feel that I have the best job in the world. On a given day, I can drop off everything, go to the ship lab and become a basic scientist, I can finish that scrub back and come back and become an administrator in the afternoon and work on compensation plans. And the next day, I can sit and write a manuscript and write on something totally different. So I think I have the most exciting job in the world as a Chair of Pediatrics. And as a researcher. I think I was fortunate to have really wonderful mentors along my career who taught me that unless I'm enjoying what I'm doing, I shouldn't be doing that. And so that's the motto I have taken. And I enjoy every aspect of my job right now. And that makes life exciting.


Ben 55:46

That's awesome. I think since we're talking about your research, I love your papers. They're always asking questions that are. I mean, I'm going to try to I'm gonna try to moderate that home on the questions you're taking on are so basic, and yet we're like, oh, man, we haven't figured this out yet. And then you go through your paper and your end. And so I was talking about this at the beginning of the show, I think you have this wisdom towards our field where there are some questions where sometimes we can get really into the nitty gritty, right of like, Oh, should I should I do a caffeine dose of five procurer or six procure, but your papers always address much broader issues like Target saturations? Or, in the case of of your work on pulmonary hypertension. You're talking a lot about pulmonary vascular physiology. And I'm just wondering, what are some of the questions that you're looking at in the field of neonatology? And you're like, This is something that we need to answer very soon, because we tend to forget about them, like Target saturation is still is still a problem. And we still haven't answered that. I'm curious to see. What are the questions that you identify as probably our priorities?


Speaker 3 56:57

That's a great question, then, the fortune of being an active clinician is that every day you walk into the unit, you realize that there are so many questions in Unit audio to the unanswered. And then once you pick those answers, you when you walk into a lab, you can realize you realize that you this is something that you can at least test your hypothesis in a well established animal model. And if things succeed, you can bring it back to the, to the clinical setting. So so the problem always arises at the bedside, then you try to find a solution at the bench and then you bring it back to the bedside. And that's the most fun that you have in neonatology at this time. So what am I currently working on? I'm currently looking deep into term babies with pulmonary hypertension associated with hypoxic ischemic encephalopathy. We are seeing an increasing number of these babies who get referred to us with meconium aspiration syndrome. And then they develop some primary hypotension, they get cooled and PPHN gets worse and then the land on ECMO. So this is a cohort that I think we really need to understand the physiology better as to what's happening here, and figure out how to optimize co2 targets how to optimize oxygenation, subtarget, as you mentioned, and figure this out. Because if you think from a historical perspective, neonatology, or actually, critical care has always been a balance between how to support the lungs on one hand, and how to support the brain. On the other hand, you give more oxygen, the lung is happy, but the brain and the eye are not happy. If it gives us oxygen, the brain is okay and the eyes are okay, but the lung is not happy. So, so we work on it fine line to make both the lung and the brain happy. And one of the beauties of being a neonatologist is that you don't have to give up on any organ system and become a nephrologist. I can forget everything except the kidney. But honestly, if you're a neonatologist, you can neglect anything, right you take care of a whole baby as a whole. And that's what makes life more exciting for us. And balancing between different organ systems is what is really critical in intensive care and finding answers to those as to creating a optimal management strategy that improves outcomes of the lung, the heart and the brain is something that I feel very passionate about. And that's what most of my research now is. At the same token, neonatal resuscitation is something that I feel very passionate about. And so a lot of animal model work that we do at the lab. Thanks to my excellent mentees who do most of the work now is looking into various aspects of neonatal resuscitation. I think that's critical.


Ben 59:42

I saw that you had a paper on the on the use of right fit to online models and and titrating either up or down basically. And that was that was quite cool. What I know you mentioned Robin Steinhorn. And I know she's she's an extremely inspiration No person. So I'm not really surprised that you are passionate about pulmonary hypertension. But what is it about pulmonary hypertension aside from the interplay that it created between the heart, the lungs and the brain that you find so fascinating.


Speaker 3 1:00:14

The the fascinating aspect is that every single one of us when we were fetuses, we had pulmonary hypertension. And we tried so well, I mean, it fetal pulmonary arterial pressure is somewhere like 60 to 70 millimeters of mercury very, very high number. And when I mentioned those numbers to my cardiologist wife, it's like, how can a fetus even survive. So, so many things that the fetus does so beautifully, is something that we need to copy and emulate when we take care of patients outside the uterus. And that really goes to tell the importance of placenta and the mother in nurturing a fetus. I often tell during my talks, I mentioned the fact that a fetus is a perfect parasite. And mother willfully gives every ounce of anything glucose, calcium, whatever to the baby at, often at a risk to herself. And, and that doesn't change once the baby's born, it stays on for the rest of your life. And so mothers are unique beings. And so our placenta, and emulating what the placenta does is the job of the neonatologist. And I don't think we are doing very well on that aspect. But there is a lot to learn from the placenta.


Daphna 1:01:26

And I have a different kind of question. And we're finding we have lots of trainees who listen to us. But as the trainees are getting invested, they're asking their, you know, supervising physicians to listen to the podcast. And it's obvious through how you speak and I've heard you speak a number of times and when you give lectures and in your varied research interests, that you really value, the individuals that you work with and what they bring to the table. And I wonder if you have, you know, a message or guidance for people who are maybe are higher up in the administration or chairs of their department chiefs have their divisions about how to how to value the people that they work with?


Speaker 3 1:02:18

That's a great question. If I compare mentees to children, when you are a parent, you realize very early that achieving something by yourself, use your less, less enjoyment compared to what your child achieves. Similarly, as a mentor, I fully realize that, you know, whether I get an award or not, doesn't really matter. But when I see my mentee get an award or somebody coming to me and saying that, Oh, your mentee did a great job that that's what brings them joy as a mentor. And grand mentees or I call them grand mentees, your mentees, mentees are like grandchildren, that's the best group to look at. And now I'm so proud of seeing many of my mentees, mentees get awards at PHS. And do so well. And that's so rewarding to see. So my what I tell people have just become chiefs and young physicians who have taken on administrative roles is that nobody will remember you for the fact that you balanced a budget or you did something everyone will remember you for what you did to junior faculty in your department and junior faculty and trainees in your department. Those are the people that will carry on your legacy. And if you worked hard to give a given junior faculty member adequate time and supported them to flourish in their career, you will often and for a long time be remembered as somebody who advanced one person's career. And that's the most rewarding part of being an administrator. I mean, being administrator comes up with its own headaches, don't get me wrong, it's it's a it's a challenging aspect. But the most rewarding aspect of being an administrator is the fact that it gives you the ability to identify talent early, nurture that talent in junior faculty and trainees and help them advance and when I see various people that have played a critical role in my career, I often think back and thank them, and it would be somebody that you have worked with and somebody you have not worked with. Just to give you an example. I had never spoken at PHS. And my first opportunity to give a plenary talk at PHS was given by Dr. Judy Asner that many of you know and she not only gave me a chance to speak and then she came to the podium mic at PHS in a hall with like 1500 people and said that openly said that oh all the illustrations that you saw on his slides were drawn by him and that was one sentence by Judy Asner make my made my career take off so, so there are so many valid wishes that play a role in your career and nurturing young people is really critical. And that's what you can do so well as an administrator. And that's an aspect that we as administrators should not forget.


Daphna 1:05:11

I love that because, you know, we talk about this a lot on the podcast, that there's so many bright, excited, passionate people coming into our community. And because of some of the modern needs of medicine, you know, we're we're missing out on all of the things that that they might have done. If they had, you know, different opportunities are different mentorship, or, or we were in a different time in medicine.


Unknown Speaker 1:05:43

That's absolutely true that.


Ben 1:05:46

My last question for you such an is going back to this article on the business of medicine, you talk about the qualities, the attributes and the skills that are needed for a physician leader in neonatology and you have a very nice illustration that has a lot of different attributes that I think you embody very nicely. And I wanted to ask you about one specific one that I think is, is very interesting, you have on there, an attribute that you called courage with humility, and I will let you close out on letting us know a little bit what that looks like to you.


Speaker 3 1:06:16

Great. Being a leader is not easy. And some of it comes inherently to some people. And some of it is something that you need to acquire. And a characteristic that's really important is, as you rightly mentioned, courage with humility, where you should, as a leader should be bold enough to take on tasks, a tough task, but do the job and convey the message that this task should be done with utmost humility. So my principal encouraged with communities that I do not want to ask anybody in my department to do something that I will not do myself, I will not ask somebody to write a grant, if I can't do it myself, I won't ask somebody to take a call that a foreign buyer, if I don't do it myself. So that's my, that's the way I see it. At the same token. Initially, when I started this job, I thought I would be a servant leader. In other words, lead from behind and let people take charge of things. But increasingly, I'm realizing that you definitely need courage. And there are times when you're a leader, that you need to be a dictator. And there are times when you're a leader when you need to take a step back and listen to other people. So being a situational leader takes a lot of courage. And that's exactly what I was referring to. So be bold in the steps that you take, as long as you think that's the right thing for the department, at the same token, have the humility to listen to people and take their advice. And that advice might be coming from a trainee. I mean, sometimes fellows come up with some great ideas and tell me what I'm doing is wrong. And I should have the courage to and humility to go back and correct myself and admit to my mistakes.


Ben 1:07:54

So Dan, thank you so much for making the time to speak to us today. This was phenomenal. Congratulations on all your body of work. And we will have on the episode page. The articles that we referenced on this episode, and also the link to your Twitter account where you're quite active. People can find you on Twitter at Neos, Neo sty, a n. And you are a great Twitter follower. So highly recommended. Thank you again, and have a good day guys.


Speaker 3 1:08:22

Thank you, Ben and Daphne. And what you're doing through this podcast is a service to neonatology and pediatrics in general. And I thank both of you for doing that. Our pleasure.


Ben 1:08:31

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, Nikki podcast@gmail.com. You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot the dash incubator.org. 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


Transcribed by https://otter.ai


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