#353 - 🔬 Dr. AnneMarie Stroustrup on Environmental Exposures, Research Persistence, and Leadership in Neonatology

Hello friends 👋

In this episode of At the Bench, hosts Dr. Misty Good and Dr. Betsy Crouch sit down with Dr. AnneMarie Stroustrup, Chair of Pediatrics at Zucker School of Medicine, Physician-in-Chief at Cohen Children’s Medical Center, and senior vice president of the pediatric service line at Northwell Health.

Dr. Stroustrup reflects on her path from early work in biotechnology to training as a neonatologist and physician scientist. She shares how volunteer experiences in an under-resourced emergency department shaped her decision to pursue medicine, and how her MPH in epidemiology provided the tools to investigate critical questions about fetal and neonatal exposures.

The conversation highlights her research on environmental chemicals—particularly phthalates—and their links to outcomes such as bronchopulmonary dysplasia, work within the NIH ECHO program, and the importance of large-scale, collaborative science. Dr. Stroustrup also discusses the persistence required in research, navigating funding rejections, and translating epidemiologic findings back to bench models.

The discussion concludes with her insights on leadership in neonatology, from directing divisions and fellowships to now serving as chair, balancing research, clinical duties, and family life while advocating for sustainable staffing models in pediatrics.

Link to episode on youtube: https://youtu.be/ZrY3hK5HUh0

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Short Bio: Dr. Annemarie Stroustrup is a Vice President and Director of Neonatal Services as well as the System Chief of Neonatology for Northwell Health, based at Cohen Children s Medical Center. She is also Professor in the Departments of Pediatrics and Occupational Medicine, Epidemiology and Prevention at the Zucker School of Medicine at Hofstra/Northwell.

Dr. Stroustrup received her undergraduate degree in Molecular Biology, minoring in both Biological Engineering and French Language and Culture, from Princeton University. After completing her undergraduate studies, Dr. Stroustrup joined Sunesis Pharmaceuticals, a small biotechnology company in the San Francisco Bay Area. After three years as a bench biochemist, she decided to pursue medical training in the research-intensive MD program cooperatively offered by Harvard Medical School and the Massachusetts Institute of Technology. Dr. Stroustrup subsequently completed residency training in General Pediatrics and fellowship training in Neonatal-Perinatal Medicine at Mount Sinai Hospital under the American Board of Pediatrics Special Alternative Pathway. This program allowed budding physician-scientists to progress through clinical training at an accelerated pace. In conjunction with her fellowship training, Dr. Stroustrup also earned her Master in Public Health degree at the Icahn School of Medicine at Mount Sinai.

In addition to serving as an attending neonatologist, Dr. Stroustrup leads a research program exploring the impact of hospital-based environmental exposures on multi-system adverse outcomes related to prematurity. Her transdisciplinary research interests span the fields of children s environmental health, perinatal epidemiology, neonatology, and neurodevelopment. She is the PI two distinct prospective cohorts in the NIH-initiated Environmental influences on Child Health Outcomes (ECHO) program as well as an NIH-funded translational research program based at Northwell. Throughout her career, Dr. Stroustrup has received numerous honors and awards for her work in patient-oriented research and is currently funded by multiple NIH grants.

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

Misty Good

Hi everyone, and welcome back to At the Bench, the neonatal physician scientist podcast of The Incubator. I'm Misty Good, and I'm a neonatologist scientist and the Division Chief of Neonatal-Perinatal Medicine at UNC Chapel Hill. I'm co-hosting today with Dr. Betsy Crouch. Betsy, would you like to introduce yourself?

Betsy Crouch

Yes, thank you, Misty. I'm Dr. Betsy Crouch. I'm an assistant professor at UCSF. We are all good friends now on the podcast. Misty and I are very pleased today to interview Dr. Anne-Marie Stroustrup, who is—this is going to take a minute because she’s so distinguished—the Senior Vice President of the Pediatric Service Line, Physician-in-Chief at the Cohen’s Children Medical Center, and Chair of the Department of Pediatrics at the Zucker School of Medicine.

Dr. Stroustrup, thank you so much for joining us. If you could provide a brief intro beyond the terms that I was just lucky enough to introduce?

Annemarie Stroustrup

Sure, and thank you so much for having me. It’s really a pleasure to be here. So yes, I have recently taken on the role of Chair of the department, but I am a neonatologist by training and spent 10 years as a Neonatal Division Director prior to coming into the Chair role. I’ve also, in the past, been a Fellowship Director and a Medical Director, so lots of roles in neonatology in my history. I’m also the mother of four and an avid runner. What else do you want to know?

Misty Good

That's awesome. That's a lot. I mean, certainly we’re excited to dig into all of that and really talk about your incredible career. And congratulations on your recent Chair position, that's phenomenal. They're lucky to have you. Start by telling us how it all began: a bit about your journey, your background, and what motivated you to become a physician-scientist?

Annemarie Stroustrup

Sure. I started out on the scientist track, not on the physician track. I went to college assuming I was going to study biology because that’s what I liked in high school. My father’s a scientist. My younger brother wasn’t a scientist at the time but is now a venture researcher. So, I just kind of assumed that was what I was going to do. I studied molecular biology and bioengineering in undergrad, then got a job at a biotech startup in California, where I was a bench biochemist for three years, sort of trying to decide if I wanted to go to grad school or what route I wanted to take.

While I worked in the lab, which was super fun, it was a very small startup. I was the 10th person on site, I think. It meant that I got to do everything, and everybody did everything, which was really a fun opportunity. The company still exists—it's called Senesys Pharmaceuticals. It was a spinoff of Genentech. We had Genentech biologists and University of California-Berkeley chemists. We were doing drug discovery around autoimmune and inflammatory-based diseases. So I was looking at interleukins and TNF, and looking at small molecule interactions and how to interrupt those without injections. That was the goal of the company. I was in a drug discovery role, doing technology development and then trying it out. It was incredibly creative and one of those jobs that you shouldn’t have right out of school. You should have somebody who tells you what to do, as opposed to just figuring it out on your own. But it was a really wonderful scientific opportunity. It was a job in industry, but we were a very academic group. My only Science paper came out of my work at that company. It was really fun to learn and build things and work in that Bay Area environment.

At the same time, while I was trying to figure out what to do with myself, I had a lot of friends from college who had gone to medical school. There was no formal pre-med major at my school, so a lot of the pre-meds ended up as molecular biology majors. That had sort of piqued my interest, but no one in my family was a doctor. I didn’t really have much exposure to medicine beyond being a pediatric patient growing up. I wasn’t a sick kid, just general pediatric stuff.

I got a volunteer job at County General in San Francisco, which I know has been rebuilt since then, but at the time it was very under-resourced. I worked one night a week. That was my first night shift job before becoming a neonatologist. I had a day job, and I wanted my weekends free because I was in my 20’s. So I worked Thursday nights in the emergency department. At the time, they let me do all sorts of things, I can’t believe anybody let me do that! We reset dislocated shoulders, I assisted with suturing, and I did a lot of…social management of intoxicated individuals – the various things competent volunteers are allowed to do in a busy ER.

Over the course of three years, I decided I wanted to go to medical school and that that was what really drove me. I probably wasn’t cut out to be a bench researcher, but I had caught that research bug: the identification of medical problems and figuring out how to solve them. So when I was looking at medical school, I was specifically looking at programs that would let me transition into clinical research. I recognized that although some of that scientific thought process overlaps, there are also differences, and obviously there were techniques I needed to learn. I ended up in the Harvard-MIT Health Sciences and Technology (HST) program, largely because they give you, during your first two years of medical school, 20 hours a week of protected time to pursue research. Yeah.

Betsy Crouch

I thought it was interesting reading your bio that you went the MPH route instead of the PhD route, which is not something that we've talked about a lot on At the Bench, but I think is obviously a really useful skill set. It has different, particular analytical areas. I’d love to hear more about your thoughts on that intersection or the contrast between the two.

Annemarie Stroustrup

Yeah. I had been thinking about basic science PhD programs when I took my first job. Even going into medical school I wasn’t quite sure how I wanted to make that transition. It became clear to me as I progressed through my medical education, particularly through the research program. I was very lucky to become a part of the HST program. It hadn’t had a lot of clinical researchers in it when I got there. I wasn’t the first, but it was a majority basic science and engineering program. So the natural tracks and labs that typically took students from our program weren’t necessarily what I wanted to do. I ended up finding Dr. Levine, who was an amazing mentor and radiologist. In Boston, obstetric imaging is done more by radiology than by MFMs, as it is in New York. So we worked on the fundamental question: what is fetal MRI good for? You could get reasonable images, but should you use it? It's obviously much more of a hassle and more expensive than ultrasound. When does it really add value? I spent a lot of time scanning pregnant people, looking at the images, figuring out long-term outcomes, and I got to follow those fetuses into childhood longitudinally, which was exciting at that point in my career. That question of “when should you do this, as opposed to when could you do this?” got me interested in statistics. So that led to the public health and epidemiology training. My MPH focus was epidemiology.

It took me a little while to get to the training program because of all the other things you must do to become a doctor, but I ended up pursuing the MPH while I was a clinical fellow. It came out of that desire to understand the mathematics behind those clinical research questions.

Misty Good

And speaking of those clinical research questions, a lot of your research has been focused on early exposures. Do you think that when you were in the early days, looking at these fetal MRIs and thinking about how various exposures impact pregnancy and the fetus and then baby, do you think your interest started way back then? Or did it happen later?

Annemarie Stroustrup

I think I’ve always been very curious about the “why.” It’s more amazing to think that fetal development ever goes right, considering how many things have to go right, than it is to think about what goes a little off track.

When I was a neonatology fellow and pursuing my MPH, the program at Mount Sinai (where I trained) had an MPH program that met in the evenings. So that was very conducive to being a working person. But if you’re a NICU fellow, your day doesn’t necessarily end at 4 p.m. when classes start. Thanks to my co-fellows and the training program, I didn’t take call on Wednesday nights because I was going to class. They let me spread out the MPH over three years instead of two. So there were only a couple of semesters I had to take more than one course. One night a week, instead of being on call, I’d go to class.

Mount Sinai has a really, still has a wonderful children's environmental health program, so a lot of their MPH curriculum is, you know, taught with that lens. And we were learning at the time a lot about these chemical exposures during pregnancy that have long-term impact, particularly on child neurodevelopment. At the time, there was emerging research looking at certain classes of organic chemicals and how they are strongly associated with behavioral differences in middle childhood. Some of that work was coming out of Mount Sinai and some of it was coming out of other places, but that was the focus of some of the curriculum. It was just striking to me as a NICU fellow how much plastic we use in the care of our patients who are, from a developmental standpoint, late second and third trimester fetuses. We all know that neonates have much higher risk of behavioral challenges in middle and late childhood, even early childhood. A lot of those are not well explained by gestational age or degree of illness in the NICU. There's not a lot of structural brain imaging that correlates greatly to those behavioral challenges.

So it occurred to me that maybe we're doing this. Maybe some of the equipment we're using is providing exposures that if neonatologists thought about environmental health science research, we might be able to avoid. It wasn't my fellowship project, but it was immediately after fellowship. I was a senior fellow, I started applying for research funding and actually not on this topic, but in parallel, I was talking to my environmental health mentors. Soon after I graduated fellowship, I received a small project grant to look at that question and to collect bio specimens from infants in the NICU. Other people had done it in other NICUs across the country and had shown that there were elevated levels of this family of organic chemicals called phthalates in the urine of babies in the NICU. So we knew the exposure was there, but nobody had ever looked at outcomes. The reason for that largely, when I talk to some of these people, and this is a plug for junior people out there, if you read a paper that's really interesting, you can just email the author and ask them a question, and they're more than likely going to answer! It’s such a compliment.

I had the opportunity to meet Russ Hauser, who was working in the Harvard system as an environmental scientist. He had written a paper about phthalate levels in babies in a NICU on the South Shore greater Boston area. I called him up and I was like, has anybody ever looked at outcomes? Like I see your papers, I see Antonia Calafat, who worked out of the CDC, who had developed a lot of the technologies for measuring these chemicals in urine. You all have elevated levels, but does it mean anything? And he's like, well, we've never really been able to do that study because NICUs are so hard to do research. And I was like, NICUs are great places to do research! It's a totally contained environment. You know, everybody gets treated with the same group of pieces of equipment. There's all sorts of data. I mean, we have like hourly data on our patients. He's like, well, the NICU nurses and the neonatologists are real tough nuts to crack. He said it in the most loving sort of way. But he got really excited. He actually ended up being quite a good mentor to me as well because I obviously was an insider. So I was able to collect urine specimens and measure outcomes and do longitudinal work in the NICU setting that many environmental scientists before me had wanted to do but hadn't really had the access, because we are very protective of our patients, understandably. That's sort of how I got started.

The other message is persistence. Like, it's easy to say from my seat now when I have lots of funding and have had lots of funding for years that that's kind of how it goes. But there was one small project grant, and then there were several years and many, many, many, many, many unfunded grant applications, then there was one more study. You know, and I think that was a collaborative effort with a lot of other people who've been in the field longer than me. My first R01 didn't come till 2023.

As a total aside, I just finished the autobiography of Carolyn Carrico, who won the Nobel Prize for the COVID vaccine. She never had an R01 funded. There are measures of success in our field that sometimes are a little arbitrary.

Misty Good

It's true, but for our listeners, you did get a K award. And it was on chemical exposures and infant outcome.

Annemarie Stroustrup

I did get a K award. It was on chemical exposures. Yeah. So that was the grant that was funded after the pilot project ran several years later. You know, multiple tries, several years later, but yeah.

Betsy Crouch

Yeah, I mean, that is the message. Which is that, like, a person is going to have varied success with individual metrics. I mean, not that this is also the be-all end-all, but I was telling an MD-PhD student in my lab currently that I never got an F-award as an MD-PhD student. She looked at me, she goes, that's comforting. You should apply for an F, because it's a good learning experience and because putting in that application will lead to other good things, other good applications, other good progress, advancement in your scientific thinking and your hypotheses.

But the F, the K, the R, one should apply for these. But if you get nothing instead of the K, you're going to be fine. You know, if you get a huge program project grant instead of an R, you're going to be fine. But you have to be engaging in the exercise of putting in these things because that actually is the foundation of the productivity.

Annemarie Stroustrup

Yeah, and the hardest part is like dealing with those rejections because they're gonna come. Like nobody gets every grant funded, particularly at the beginning, the percentage submitted to the percentage funded is like alarming. You submit 10, you get one funded. Figuring out how to deal with those responses that are negative and not taking them personally, but also not ignoring them is important. When I get the response, if I know it's a rejection, because you typically know that at the time, I'll read it quickly once and I'll get super angry and then do the electronic equivalent of stuff it in a drawer. Then at some point a little bit of time later, you come back and you actually read it and you're like, they didn't understand this. You could get mad at the reviewer for not understanding it, but fundamentally, my job as the writer is to make them understand. So taking that to heart and figuring out how the next time to be more clear. Especially in the work that many of us do most of your reviewers are not going to know anything about neonatology. I have had reviewers, paper reviewers, grant reviewers right back and be like, I just don't believe you did this. I'm like, why? I'm sorry you don't believe I can get five milliliters of urine from an 800 gram person, but I can. It's figuring out how to internalize that so the next one is better. But that's hard.

Misty Good

It's similar to if you're training for a marathon or something like that. I try to teach that to my mentees that you're not always going to get your best score running track or something every time. I'm not a big runner, but I know you are. I'm using the running analogy. I could run, but I don't like running. But you do need to self-reflect so that you can get better. And it's like, not every run that you take is gonna feel good and you're not always gonna get the runner's high after. But I do think the more training, it's hard to write initially when you're first starting out. You have to be able to communicate your science in such a way that it can be applicable to broad audiences. So trying to keep that in mind with that feedback just helps us grow. Like if we always get positive feedback, we don't get any better.

Annemarie Stroustrup

Persistence is really underrated. I mean, I think that I had a quote on my wall for many, many years, which I can't remember exactly what it said, but it was basically like the best marker of ultimate success is just keeping at it. If you quit, you're never going to get there.

Misty Good

It is true. Well, what are some of the biggest challenges over the years that you faced, either scientifically or in your leadership journey?

Annemarie Stroustrup

Oh, I mean, figuring out how to juggle. People talk about work-life balance. I don't know that there's balance. There are periods of time where it swings one way and periods of time where it swings another. Figuring out for like you as an individual or you and your family or whatever that means to you, what your outside of work life is, how to make that work, whether that be integration or having a partner who you can rely on to pick up the slack when you're not around or whatever that is. That's always a challenge and it changes over time at every different stage. Similarly, figuring out that balance between your research time and your clinical time. If you're a person with clinical responsibility, you can very easily get sucked in too far one way or the other. It's really, really hard to say no pleasantly and in such that you don't engender a ton of anger and also get asked again at some point in the future when you might have more bandwidth. I think that those are skills that certainly took me a very long time to learn. The importance of building a team, both at work and at home, can't do anything by yourself. All of these things take a village.

Betsy Crouch

Could I ask one personal question? How does one manage a research portfolio, a clinical role, a leadership role in four children? Just broad strokes.

Annemarie Stroustrup

Not always gracefully, I think is the honest answer. You probably should ask my kids whether or not that's been successful. I think we were lucky by design. So my husband and I are full partners in this. He is also a physician. He's a physician administrator as opposed to a physician scientist, but he's also at home with a pretty heavy workload. We from very early on decided that the only way this was gonna work for us as a family was to split it all. So like my husband does almost all of the cooking. I plan all the afterschool activities and camps. You know, like it's, we balance that. If I'm not around, my husband does all the stuff with the kids. If I'm not around, I do all the stuff with the kids. At different points during our careers, different ones of us have been sort of more the functional primary parent for various periods of time. I think that when the kids were little, we also had a lot of family support. We came to New York specifically so that we would be either very close or occasionally living with my in-laws depending on the period of time. My parents, even though for a good portion of my children's young lives, they lived in Texas and we lived in New York, my dad was a professor and so they spent a lot of time during the summer helping with the kids. So we have been lucky to have very involved families and even like my brother-in-law was my daughter's first babysitter. You know, I think we've been lucky with that. We've had au pairs and babysitters and all sorts of other people to be helpful. I must say living in New York City does make it a little easier. You know, I've never had to drop off and pick up at soccer practice because from age 10, your kids can take themselves.

Betsy Crouch

Cool. We're getting close to that. There were, I mean, we lived in San Francisco and there have been coyote sightings by me personally on my way catching the bus to go to the lab. I was thinking how large my children need to be before they aren't tasty to a coyote.

Annemarie Stroustrup

That's not something I'm worried about in our city. I think finding those solutions to how you can have, obviously, be present in your children's lives or your extended family's lives or your friend's lives or whoever it is outside of work while also doing what you need to do at work. I'll be honest, when my kids were young, I didn't do anything other than work and children. It wasn't like there was now that they're a little bit older, there's a little more opportunity to go running occasionally. But like, you tear things down when you need to.

Betsy Crouch

Yeah, but I mean, I think just to celebrate this. You and Brenda Poindexter have four children each. There’s a beautiful spectrum of family decisions that people might make as physician scientists. So thanks for letting us go on that tangent for a minute.

So, okay, so that was a challenge. I wanted to get, like, I had so much fun even just perusing the PubMed page where I put in your name because I could ask, I mean, we could have an interview about every paper that you've written but maybe we'll stay on the science for a minute. Could you pick maybe something from the ECHO study that you feel is like the most compelling that you're proud of and what do you think has to be done next?

Annemarie Stroustrup

Right, so I will give a two second background to ECHO because you alluded to that. So ECHO is the Environmental Influences on Child Health Outcomes program that was started a decade ago by NIH. It's a contract grant, so they brought a whole bunch of people together. We wrote a protocol and then brought existing cohorts into that protocol, recruiting some new participants, and we're still recruiting some new participants, but also just following people who have been recruited into other studies previously to look at exposures, initially during pregnancy and early childhood up to age five, and now we've included a preconception portion of the cohort looking at environmental exposures, very broadly defined, and then long-term child outcomes that fall into neurodevelopment, obesity, airways (asthma and allergies), and positive health, which is something that we don't study so much in science. So, you know, what leads to good outcomes as opposed to what leads to bad outcomes and obesity. What can we recommend for instead of just recommending against? So this was the NIH's sort of second attempt at a national environmental health cohort, which is a concept that exists many other places in the world. Many countries in the European Union all have child environmental health cohorts that have been ongoing for a long time. We were lucky to be selected to be part of this initially with a cohort of children born preterm across initially 15 and now slightly fewer than that size across the United States. Then three years ago, we added a second cohort based at Northwell, my current institution, that's just pulling from our general obstetric population, which we recruit in Queens, which is the most diverse, and I like to use that word, most diverse county in the United States, most languages spoken, lots of immigrants. It's a really interesting place to work and bring in people from all sorts of backgrounds into the ECHO program. In ECHO, you can look at any of the exposures that are measured, and those are some chemical exposures, like what I've focused on previously, and also social exposures, and kind of built environment, and air quality, and all sorts of things, and look at a wide set of outcomes.

So to get to your specific question, I think I'm most proud of the work that we did that was actually within our specific group of preterm patients. We've done many other studies looking across ECHO nationally at sort of more broad-paced exposures, but looking specifically at preemies and the impact on lung development of early plasticizer exposure, of phthalate exposure. We identified a specific link between these chemical exposures and development of chronic lung disease of prematurity or BPD in a cohort that's spread across eight sites in the United States. The reason why that's so important is that it led to a study that's ongoing that we have two papers under review. But we actually transitioned into an animal model. So we went back to the bench. So this was an epi study that was enabled entirely by basic science in biochemistry to be able to measure these chemical components in child urine. Now we've taken it back to an animal model to look at the pathways in which these chemical exposures might impact lung development. That then we can hopefully, again, bring back to the clinical side and direct manufacturers about which specific chemicals they should avoid in our respiratory circuits to impact pulmonary development in children and in NICU’s nationally.

Misty Good

There’s so many different exposures that one individual goes through that touches a person throughout their lifespan. So I’m just wondering if you could talk to our listeners about what are all the different exposures? I know you had a paper on public water concentrations of arsenic. How do you control for everything? But then two, how do you collect all that data and who collects it? And maybe you could share with us.

Annemarie Stroustrup

Yeah, so I’ll start with the how do you account for it. I am extremely lucky to have had the privilege to work with the environmental health statisticians at Mount Sinai. So Chris Jennings and her team are amazing. They’ve developed all of these really robust methods in collaboration with other people elsewhere, I’m sure, to be able to look at mixtures. So you can take all the different exposures that are happening at the same time, even if you just talk about phthalates, which is one class of one organic chemical, there’s like 15 different separate species that we measure. The exposure to those is all at the same time. They’re not individual. They’ve been able to come up with weighted regression approaches that you can pick out those that are most closely tied to the outcome you’re interested in. I’ll be very honest, the math for that’s over my head, but that’s why you have collaborators.

Betsy Crouch

I will say you’ve given me so much more appreciation for statistics. You have a wonder when you describe statistics that I have not been able to capture personally. I’m a bench scientist. I like beautiful micrographs, ideally with Imaris 3D rendering. It’s really delightful how much joy you take in your statistics. I’m thinking of my colleagues, my friends who are also excellent clinician scientists. It’s true, the way that they can take a statistical model or a logistic regression and wield it, you know what I mean? Wield it in this beautiful way to put a chart, to take a chart and make it make sense. Ben and Daphna one time were talking about a study and they said, and Ben was like, “Please not another chart! Please, a graph!” And I feel similarly, but you know, those are good numbers in those charts.

Annemarie Stroustrup

And, but I think to your point, you do have to go back and validate it because the world is messy and you know, and there’s no way to have a clean experiment and a baby while you’re taking care of them in the NICU. I mean, you’re going to do what you need to do to. None of my studies have altered clinical care. This is all observational. We are looking at what happens in the world and whether we can identify things that we think we could do differently to impact the outcome. I don’t do clinical trials in the interventional clinical trial model. I do observational studies.

Misty Good

We are in awe because it’s not just an observational study. It’s like we’re observing the water and the air particles and all of the socioeconomic factors that are impacting that particular baby and air pollution. I mean, just it’s just really remarkable, like all the different exposures.

Annemarie Stroustrup

Well, and that’s the beauty of team science. That is the beauty of working in a very large collaboration. When we have big in-person ECHO meetings, which we do twice a year, the big meeting is the spring meeting where we invite our research coordinators and the whole broad team. There’ve been 1,200 people at those meetings. This is not stuff I do. This is stuff that I know people who do. Then we work together. The research coordinators really are amazing. The ECHO protocol is a beast. It took hours and hours and hours and there’s biospecimen collection and there’s survey collection and there’s anthropologic measurements and you’re following these people longitudinally. I mean, the program itself has been going on 10 years. Our oldest children are turning, I want to say 15 this year, our oldest preemies. Kudos to the families for sticking with it and to the research coordinators who are so engaging that the families stick with it and can collect those data and those biospecimens. Thank goodness for the biochemists who can measure all sorts of things and all the biospecimens we collect. To the environmental scientists who’ve figured out how to do the air pollution modeling so that you can put in a zip code and know what the air quality was like during that period. We have amazing techniques where we can look at all of our biospecimens. There’s amazing techniques to look at teeth through development from in utero to when they’re shed at age six and see what on almost down to the day, what certain exposures were. I mean, it’s really amazing stuff.

Misty Good

That’s incredible. I always say I don’t want to intubate anyone with teeth like that. So teeth are not something that we see that often.

Annemarie Stroustrup

Yeah, but we collect them when they fall out of our ECHO participants. When you lose your teeth at six, we send a little tooth fairy kit and we say, please send us your tooth and here are some stickers.

Misty Good

That’s adorable. I love that story.

Annemarie Stroustrup

And people do. So I think that that’s also really the message is that this sort of science takes a really large team. Then the ability to come up with those robust statistical methods to identify these very specific associations that then you can take back to the lab. Like in my animal experiment, we have one type of phthalate that we expose our rats to. And then we can go and look at the impact of that on each specific organ development at various points in development. That’s your controlled model. Provide the evidence that then ultimately from a policy and impact perspective, you can take back to the manufacturers and say, don’t use this phthalate, use that one. It may be two pennies more expensive, but you’re not going to create BPD in these children. It’s not the only thing that has a risk of BPD for children, but if it’s something we can control because they’re in our care during that period.

Misty Good

Yeah, that’s really profound to be able to shape the future like that.

Annemarie Stroustrup

Well, that’s the goal. We’re like three quarters of the way there. So not quite there yet.

Misty Good

That’s awesome. What are you most excited about that you’re currently working on?

Annemarie Stroustrup

The dead animal model is exciting. We’ve just started to look at kind of all the data that we are collecting where we just finished year two of a five-year grant. So we’ve got a little bit of lead time to kind of work on that. I think I’m also really excited as the ECHO program continues and our children get older. We recruited over a very long period of time in our cohort. We had to stop recruitment during COVID; we had planned to recruit through 2020 and then the world had different plans. Our youngest children are turning five and our oldest children are teenagers. So being able to have a large enough number of participants, all who have the same outcome data and the same biospecimens to be able to look at this the various questions that we have over a big enough group of children to be able to have an answer is going to be really exciting. The total number of participants is somewhere in the order of six to seven hundred. There are more preemies than that in the ECHO consortium because we are not the only preterm cohort, and some of the “regular non-preterm cohorts” that have preemies in them because preemies are born everywhere. So the overall number of children you can look at if you’re looking at preemies is I think close to two thousand at this point. So it’s different than NICHD because the focus is different, but it’s still a large enough sample to be able to actually draw some conclusions.

Betsy Crouch

Yeah. Can I ask one? I’m going to act like I’m a reviewer for a second, but why did you pick the rat to model the phthalate exposure?

Annemarie Stroustrup

So there's a couple of practical reasons. Mice are too small to do some of the lung stuff that we wanted to do. I will say this is the work of Shahana Perveen. I am not an animal modeling person. I have never worked in a rat or mouse lab at all. But Shahana had worked up a couple of different animal models, some using rats and some using mice over the years. There’s an established rat model of BPD that we basically adapted with an exposure chamber that Shahana bought the components and got it all put together and the monitoring. So now we can do inhalational exposures of all sorts that correlate to the preterm period. We can do it without having to intubate these rats. The concerns that you have about barotrauma and volume being confounders are gone because they’re all free breathing. It really is just whatever the inhalational ambient environment is as opposed to other components that we know contribute to BPD.

Betsy Crouch

We have many, many tools these days, a bunch of different animal models that have varying degrees of complexity, but also considerations for taking care of those animals. Of course, the human microfluidics chips are a hot topic. You know, as a person who’s doing some of that, they have drawbacks as well. Rats don’t have the genetics that we have in mice, but yes, they have major advantages in terms of their size.

Annemarie Stroustrup

Yeah, and it’s definitely a starting point. Like this was our first foray into trying to look at inhalational phthalate exposure in a basic science mode. We’ve identified some pathways and then we’ll probably be back in cell culture. There’ll be other things that come out of this.

Misty Good

That’s really awesome. I wanted to pivot a little bit and talk about your leadership journey. You’ve done so much for the neonatal division directors, for sure, heading up that group. But I know you’ve helped several leadership positions over the years. Maybe you could talk about your leadership journey and how maybe one thing led to the other or how they all came about now with your incredible chair role.

Annemarie Stroustrup

Sure. I was a faculty member at Mount Sinai. I was on a K award, was sort of research track junior faculty. Our division director had been in the role for a very long time and was headed towards retirement. I was asked to take over as the division director at that point. I think I had already been the fellowship director for a year or two. I should probably know my own CV better, but I think that was the order of events. If was a very small division; I think there were five of us when I joined the faculty right out of fellowship. The division director was also the fellowship director, also the medical director for the NICU, and the medical director for the newborn nurseries. So he wore a lot of hats, way more hats than I ever wanted to wear. So at some point I was fellowship director and then when he was headed towards retirement, the chair asked me to take over as the division director. I think in a mode of self-preservation, I accepted as long as I could split out the jobs. So we hired a separate medical director for the newborn nursery, a separate medical director for the NICU, and grew the program a bit over that period of time. We were working on integration with other hospitals in our health system. So there was a fair amount of leadership opportunity there to grow that NICU team. It was, for New York size NICU, a relatively big busy NICU, relatively big delivery hospital.And then I had been in that role for approaching five years and I got called by Charlie Schlein, who was the chair at Northwell at the time, who said his division director was retiring, would I be interested in the position? And I honestly told him I wasn’t looking, I was pretty happy where I was. But the Northwell footprint for pediatrics is quite a bit bigger than it was at Mount Sinai where I had been. So he sort of told me about the position and the opportunities and it seemed like an interesting opportunity in terms of sort of leadership and administration to work in a health system that at that point had 10 hospitals that deliver babies. But also, you know, at heart I’m an epidemiologist and there were 30,000 births in the Northwell Health System at that point in time. So the idea to be able to kind of like grow the platform there was also really exciting. So I ended up transitioning over here about five years ago.Now we have seven additional hospitals that care for children, six of which deliver babies, approaching 40,000 births a year in our health system. So again, as an epidemiologist, these things are all really exciting and across a very big geography. So those have been fun sort of administrative challenges. The team here is a lot bigger. Obviously, we have many, many more neonatologists, the neonatal team approaching 100 physicians, and a lot of nurse practitioners and 12 fellows and the whole nine yards. So that has been a journey of certainly growth and learning. Then my boss announced he was going to be retiring and so I applied for the job. That would be my other leadership lesson – you have to apply for the job. These things do not land in your lap, counter to what some people may think. There were like five rounds of interviews and I was lucky to get it.At Northwell, it’s a really interesting position because there are a lot of titles. There’s the academic title and then there’s the health system title. Those really are distinct but complementary roles. In pediatrics at Northwell, it’s not true for every specialty and it’s not true for every institution, but those have been held by one person, both my boss and now I hold both. And that’s kind of a fun challenge. Like there’s the administrative business management side of it, which I find really interesting. But there’s also the much more traditional academic side. I still have my research. Like that hasn’t gone anywhere. As I said to my research team, this is the one part of my job that’s staying exactly the same. I am so grateful for that.It is an incredible group of people across the whole health system and it’s really a wonderful place to work. So obviously, I wouldn’t have stayed had I not been having a good time here.

Betsy Crouch

Do you have any reflections on neonatologist and leadership roles? Because I think that’s the other part of your PubMed page that I find really fascinating. Tell us about your paper “Consensus Recommendations for Sustainable and Equitable Neonatology Staffing: A Delphi Approach.”

Annemarie Stroustrup

Well, I take very little credit for that. I was invited to be a part of that group by, I think, Carrie Masho was the person who actually invited me, but there’s a team of really wonderful women leaders in neonatology who have been working on workforce issues for many years. I don’t want to take any credit for that. But it’s been really fun to be part of the discussion. Neonatology as a very young specialty has not explicitly codified what a job is. That comes out of the days when there weren’t enough neonatologists. So every hospital hired a neonatologist to cover their delivery service. That person eventually was able to hire a second person because there was a second trained person. At my first job, I was hired just under the work schedule of all the work divided by the number of people we have. That was the common model. I was the fifth person hired and the boss stopped working weekends. So we worked one and four weekends and we split the call pretty evenly. You know, I got a little bit less service time because I had a research career, but that was how it was done. That was true for everybody, whether you were in a group of two or a group of 15. I think that one of the things that has become apparent over the years is that as there is now a workforce to support, you hate to say physician-centric, but it is a physician-centric staffing model as opposed to an organizational-centric staffing model, you can figure out what is a reasonable work schedule as opposed to what is going to put somebody in the seat all the time.And so that’s the work that’s being done. That has a lot to do with combating burnout and a lot to do with patient safety. If you don’t really want to be taking care of your child for 48 hours straight, that’s not good for anybody. We’re privileged to be at a point where we have enough numbers to be able to make those sorts of arguments and determinations. But it’s hard. I mean, there’s a financial cost to this. Health systems don’t always want to hear that.

Misty Good

I was going to ask because I think that’s one of the biggest issues: we have a hard time defining what is a neonatologist job or what is a 1.0 clinical FTE, for example, in various types of units. You’ve done a lot of work in that regard to help standardize that. I’m just curious now that you’re in your new role and there is a cost associated with defining that 1.0 clinical FTE for neos, how do you see either your lens shifting or, or I don’t know, advocating for additional personnel resources to be able to meet the recommendations?

Annemarie Stroustrup

Yeah, I mean, think medicine is in a tough place right now. It’s not just pediatrics or neonatology. You know, if you actually look at it as an outsider, the economics don’t really make sense to do what we do. The way that health care is financed in the United States is fundamentally and systemically broken. That’s true for everyone. So from my perspective, like, yeah, we do our best to balance the budget, but it is more expensive to have faculty burn out and quit than to add one more FTE to a group of 40 so that everybody can have a little bit more of a normal work schedule. I know senior administration is in a hard place. I don’t know what’s going to happen to health care going forward if this financial squeeze continues. We’ve already seen this across the United States. Hospitals are closing, not opening. This has been for a while. This isn’t like a last two years phenomenon. This is quite a long time in coming. We still spend more on health care in the United States than many other countries with similar or better outcomes. The system is a problem. But in my role, I think I do have to advocate for our faculty. I also have to balance the budget.And sometimes those two things are diametrically opposed. So you do your best to figure out a middle way. So the budget’s going to be close but not perfect. The faculty are going to be OK but not as happy as they could be. Fundamentally, if you can take good care of patients, then I’m happy at the end of the day. If you can’t take good care of patients, then something has to give. We have to make sure that that’s our priority. That’s my view.It’s a neonatology problem, but it is an everyone problem. I think that, you know, saying that we’re special or unique and the only ones having this problem is totally untrue, but not acknowledging that it is a problem is also not helpful.

Betsy Crouch

Yeah, exactly. I find it very hopeful about, to call out another leader in this space, Satyan, is just to say that he is constantly pointing out the ways in which we need to improve, primarily as neonatologists, and also not giving up, keep going and figuring out new solutions and that’s how we move forward. So yeah, thank you also for serving as one of our leaders and one of our sources of inspiration. Well with that we’ll wrap up this interview today. Thank you so much for joining us Dr. Stroustrup. Thank you, Misty, for co-hosting with me. It’s always a blast and thank you so much to our listeners. Feel free to give us feedback and we look forward to talking to you soon. Take care.