#321 – Exploring the impact of prematurity on caregiver employment decisions (Dr. Erin Von Klein)

Hello friends 👋

In this episode, I had the pleasure of speaking with Dr Erin Von Klein, who is now a third year Neonatology fellow at Monroe Carell Children’s Hospital/Vanderbilt University, Nashville. Erin described her research project on exploring association between caregiver employment decisions and having a preterm infant. Erin describes her project which was also recently published in JAMA pediatrics (Preterm Birth and Caregiver Employment Decisions | Reproductive Health | JAMA Pediatrics | JAMA Network) where she investigated the impact of prematurity in parental employment decisions. She describes how she got interested in this impactful topic and how she found her mentor. She is a 2024 recipient of the AAP Marshall Klaus Award in Health Services Research and a participant in the Vanderbilt Patient/ Practice Outcomes Research in Effectiveness and Systems Science (PROgRESS) T32 Program. In this episode she describes her experience in grant writing and winning the AAP Marshall Klaus award. She also provides valuable advice to incoming fellows who are interested in the physician scientist pathway in health services research. 

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Short Bio: Erin grew up outside of Chicago, IL. She obtained her B.A. in Biology from Dartmouth College before receiving her M.D. from Washington University in St. Louis. Afterward, she headed back to Chicago to complete her pediatric residency at Northwestern. She is currently a third year NICU fellow and enrolled in her Master in Public Health at Vanderbilt University. Erin's research interests include the economic, psychosocial and physical health outcomes of prematurity on patients and their family. 

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

Srirupa:Hello everyone. Welcome back to another episode of the Fellow Series with the Incubator Podcast. My name is Rupa. I'm one of the newer attendings on the block, I suppose—I just graduated recently from fellowship. I'll be your host for this part of the Incubator Podcast.

I'm very excited to welcome another guest today: Dr. Erin Von Klein from Vanderbilt University. She's a third-year NICU fellow at Monroe Carell Children's Hospital. I'm thrilled to have her on the show.

Erin did her medical school at Wash U in St. Louis, so we share a connection there since I'm currently in St. Louis myself—I call myself a St. Louis person now! She did her pediatric residency at Northwestern and, as I mentioned, is now doing her neonatology fellowship at Vanderbilt University. That's another fun connection because I lived in Nashville for a long time and have fond memories of Vanderbilt.

Welcome to the show and thank you so much for joining us to share your fantastic research at Vandy. Why don’t you take some time to tell us about your research, and then we can dive into all the great things you've been doing during fellowship.

Erin Von Klein:Thank you. Thank you for that very kind introduction. I’m an aspiring health services researcher and have spent my fellowship building skills in both quantitative and qualitative research. My project, which was recently published in JAMA Pediatrics in October, is a quantitative study using data from the National Survey of Children's Health from 2019 to 2022. It was a secondary data analysis exploring how having a child born preterm or low birth weight is associated with a parent's employment decisions. Specifically, we looked at whether parents were more likely to keep a job to maintain health insurance for their child, reduce their work hours due to the child's health needs, or leave the workforce altogether.

Srirupa:That’s fantastic—so impactful and so relatable. Welcoming a child is already a big life change. That impact is even greater when your baby spends time in the NICU. It adds to the stress and complexity of the postpartum period, not just for mothers recovering physically and emotionally, but also for fathers. I think this is such an important topic. What got you interested in researching it?

Erin Von Klein:I became interested in this topic because I saw firsthand how it affected the families I cared for. No matter where you are on the economic spectrum, having a child born preterm poses serious challenges. I had one mom who was a CNA in nursing school and had to drop out, and another parent whose child had congenital heart disease requiring multiple surgeries—he dropped out of law school. Those changes will have long-term financial consequences for their families.

Most people have children before they hit their economic prime. So when a doctor tells you, “Your child has BPD. If they go to daycare, they could die,” or “Even a common cold could lead to hospitalization,” or, for medically complex babies, “Someone has to be with your child 24/7.” We don't explicitly say, “You have to quit your job,” but that’s often the implication. Unfortunately, our society hasn’t caught up with how far we've come in saving and discharging these fragile infants, especially in terms of supporting the families afterward.

Srirupa:Yeah, absolutely. So what did your research ultimately find? Would you mind sharing the results?

Erin Von Klein:Of course. The National Survey of Children's Health is often used to study kids discharged from the NICU. It’s conducted every year and is sponsored by HRSA (Health Resources and Services Administration). It represents U.S. non-institutionalized children and oversamples those under five and children with special health care needs. It’s a great dataset, though one challenge is that the only prematurity-related question is, “Was your child born three or more weeks early?” So we categorized the babies as: preterm and very low birth weight (under 1,500 grams), preterm and low birth weight (1,501–2,500 grams), or term infants over 2,500 grams (which we used as the reference group). There’s no ability to have any more granular data about the gestational age of these infants.

We then analyzed whether parents in these groups made any employment-related decisions in the past year—whether they kept a job for health insurance, reduced work hours, or left the workforce entirely. We found that these types of employment decisions were common across all groups, but especially so among parents of preterm infants: 13% of parents of term infants made at least one of those decisions, compared to 20% of parents of low birth weight/preterm infants did and 30% of parents of very low birth weight/preterm infants did. So the need to adjust employment based on a child’s health is clearly a significant and common issue, particularly for parents of the most vulnerable babies.

Srirupa:That’s amazing. Tell me—how did you find your mentor for this project? This is clearly something you're passionate about. What was the process like for finding mentorship and uncovering these insights?

Erin Von KleinSo I think I probably met with about 20 different people during the first six to eight months of my time at Vanderbilt, exploring options for different mentors. Part of the challenge is that while health services research or health equity science is becoming more common, it's not yet widely done across the country, at least not in the NICU. That said, more and more NICU fellows are becoming interested in this type of work and forming careers in health services research and this kind of science.

I was fortunate to have Steven Patrick at my institution—he’s a fantastic researcher and very experienced in health services research. I met with him, and he joined my scholarly oversight committee, but he didn’t have the bandwidth at the time to be my primary mentor. He connected me with someone he had mentored—who actually has a PhD in health policy and works at Vanderbilt—and that person became my primary mentor. It’s been a fantastic working relationship.

One of the other mentors on my SOC is Joe Zickafoose. He’s in general pediatrics but also has great experience in health services research. So those two were really helpful. I think what’s a little atypical about my mentorship team is that I actually cold-emailed another faculty member. I reached out to Meg Parker at UMass after reading her papers for a few years. I told her I was really interested, trying to figure out a project, and having a little bit of trouble. She said, "I can be your primary mentor," and was so happy and willing to take that on. She’s been a great mentor and sponsor.

So those four—Gilbert Gonzales, who is my primary mentor, and the other three I mentioned—became a really solid team that has advocated for and sponsored me. That’s been incredibly important. For example, last year at PAS, Dr. Parker put all 13 of us she mentors across the country on an email thread and organized a dinner. She gave these beautiful introductions of each of these wonderful, talented, young female physicians—highlighting their work and helping us build a network. I’ve kept in touch with a few of them since. Having a great team really is critical, and they may come from unexpected places.

SrirupaYeah, for sure. That sounds very familiar to how I found my mentors too. It’s so interesting that the world is so connected these days—you just need an email and a little bit of attention. Hopefully, your email doesn’t go to the spam folder! But once you do get that attention, the doors that open in the process are just beautiful. The amount of networking that comes out of it is amazing. I applaud you for finding your pathway during fellowship. That’s wonderful.

When I was reading your bio, two things stood out that I’d love to highlight and talk about. You are an AAP Marshall Klaus Grant awardee, so let’s talk about that first, and then we’ll discuss your T32 grant. Those are both such impactful accomplishments during the very busy time of fellowship. So, share with us how that process began. How did you decide this was something you wanted to apply for, and how did you react when you found out you’d received it?

Erin Von KleinThanks! It was quite an honor. So, about the Klaus first: there was a third-year fellow at my program during my first year who had received it, so I was aware of the grant because of that. Even as a resident, I had come across a few awardees and thought it was something I’d want to pursue. Dr. Parker had multiple mentees who were Klaus recipients, and she connected me with a few of them. One was only one or two years ahead of me and shared their successful grant application, resources, and even things they wished they’d done differently. Between those resources and people at my institution who shared their T32s and foundation grants with me, I felt like I had a sense of what a good grant looked like. As a fellow writing my first grant, that was incredibly helpful. It can be really intimidating.

I met with my mentorship team and said, “Here’s the dataset I want to use. Here are six potential hypotheses I think I can explore.” They helped me narrow that down. They said, “Any of these three are good—go with what you're most interested in.” The paper I wrote for the Klaus and the T32 came from that, and it was a topic I was genuinely passionate about. That made it easier to write and explore.

The T32 took me a bit longer to come around to. Most people apply during their first year of fellowship, but I had just moved to a new state, was adjusting to a new unit, and I just wasn’t ready. I applied the following year. By then, I had a lot of preliminary data. I'm doing a mixed methods study—I finished my quantitative work and used that to inform the interviews I’m planning with parents of NICU graduates. The interviews are about how going home with their child influenced their employment decisions, their return to work, financial security, and similar topics. I felt much more prepared to write the T32 at that point and explain how the program would help me. It’s an implementation science T32, which also includes getting an MPH. It’s been incredibly helpful, and being further along in my project definitely made the application process smoother.

SrirupaGrant writing is definitely intimidating in many ways. It involves a lot of trial and error and questioning your research question a million times. It’s such a fascinating and important skill to gain throughout fellowship.

You had mentioned interviewing parents, so I’d love to delve into that part of your project. How did the parents respond? That’s important—since they’re being asked questions about something that impacted them directly, what has your experience been in understanding their reactions?

Erin Von KleinMy first project looked at all caregivers and wasn’t restricted to parents. But for the next project, because I’m doing in-depth interviews, and it would be harder to reach thematic saturation with a variety of caregiver types, I’m focusing on parents only. We're currently on our third IRB revision, so I haven’t started interviews yet—hopefully by this winter or spring. But I’ve already met with some families to discuss my interview guide, especially those I’ve maintained relationships with from the NICU. I also brought it up in our developmental clinic last spring to gauge interest and ensure it wasn’t just a topic I thought was important, but one that resonated with those directly affected. The feedback has been pretty positive. Every family I’ve talked to has had some kind of story. One family I’ve stayed in close touch with had two kids in our NICU, born just over a year apart. The dad had to travel for work—how did they manage that with another child at home, while wanting to be present in the NICU? Regardless of their economic background or circumstances, families face a big impact—whether it’s needing time off, losing employment, or becoming underemployed compared to their skill set.

SrirupaI'm curious to know how their response will be once you actually start recruiting parents who have been affected.

You mentioned your MPH, and I want to delve into another standout aspect of your bio. Tell me about your experience—first, your decision-making around pursuing a master’s during fellowship, and second, did this project influence you to pursue an MPH, or was that already something you'd considered before starting fellowship?

Erin Von KleinI actually wasn’t very convinced I wanted to pursue an MPH when I started fellowship. We’re required to take a lot of public health classes in medical school now, with how the curriculum has evolved, and it seemed like a big endeavor. That’s part of why I didn’t apply for the T32 during my first year. If any of you listening are having a tough time as a first-year fellow—getting used to new environments, managing very sick patients—I can relate. I just didn’t feel ready to do this job well while also going to school full-time. Our program’s curriculum is heavier during first year, but still pretty intense in the second and third years too.

I became more convinced at the beginning of my second year that I wanted to pursue the T32 and MPH. I was able to shift an extra block of service into last year so that I could have less clinical time this year and fully engage with school. I was fortunate that my program was very supportive—they helped arrange my call schedule so I wouldn’t have 24-hour shifts or call right after class, unless it was a special week like Peds boards or something.

It took some coordination, but I’m really glad I’m doing it now. I'm doing the work I'm passionate about, and I’ve met a lot of people who also do this kind of work and have the MPH. I felt that to be competitive for grants, to have protected research time, and to be successful long-term, this was the right decision. But I definitely felt more ready to take it on this year than last year.

SrirupaYeah, that’s amazing. I think anyone who tries to take on more than just the core three years of fellowship is incredible. It’s such a steep learning curve, and we learn so much because we’re so passionate about the work and these babies. For many of us, fellowship is the final stage of training, so we finally get to explore the things we’re truly passionate about. I'm so glad you were able to take that step during your fellowship and continue to do an amazing job.

Now that you’ve collected preliminary data for your project and successfully published in a fantastic journal like JAMA Pediatrics—congratulations, by the way!—how do you foresee the next steps in your career? I know the next big one is a new job, but from a project and interest standpoint, what comes next?

Erin Von KleinThanks! My long-term goal is to follow the K-to-R01 pathway and become a physician-scientist and health services researcher. I want to study the longitudinal economic, psychosocial, and physical ramifications on families of having a child born preterm. We know from adult literature that having a preterm child is one of the predictors of bankruptcy, but I don’t think we’ve fully explored the long-term ramifications. There are people researching financial toxicity and related issues, but I want to go broader and deeper.

My hope is to do research that can help support or shape policies that better support these families. I’m still building the skill set to do that—finishing my MPH and working through the final year of my grant. I’ll be staying at Vanderbilt in an instructor role during that time to tie up my research projects, hopefully publish a bit more, and become more competitive for a position with protected time in 2026. So I’ll be job hunting in the next cycle.

SrirupaThat’s awesome. I think any place would be honored to have someone so dedicated—not just to improving outcomes for babies, but to supporting entire families. Like you said, if there are modifiable factors we can identify early on, we can make such a difference.

There’s definitely a growing interest in public health within neonatology, especially among incoming fellows. I forgot yesterday was Match Day! I'm sure there are a lot of excited, passionate fellows coming in. For those who might be interested in public health research, what’s one big piece of advice you’d give?

Erin Von KleinLook at the resources at your institution, but don’t feel limited to just the neonatology division. There are incredible people doing health services research across pediatrics, and even at affiliated universities. And if you’re not finding the support you need locally, look nationally—there’s a great network of researchers, many of them early- or mid-career, who are incredibly supportive. Many will help design or support projects even if they’re not at your institution. So don’t hesitate to reach out.

SrirupaThat’s awesome. Yes, this is exactly the purpose of the Fellows Corner! If anyone is interested or wants advice on how to pursue public health research, I think Erin is your gal. With permission, we can share her contact info for anyone who wants to connect. She’s more than happy to help. That’s amazing.

All right, this was wonderful, Erin. Thank you so much for joining us and sharing your passions and interests in public health research. This is such a unique and impactful space, and I think you’ll inspire many of the incoming neonatology fellows.