#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 (00:01.229)

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. And I'm co-hosting today with Dr. Betsy Crouch. Betsy, would you like to introduce yourself?

Betsy Crouch (00:19.618)

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 Struestrup, 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 pediatrics at the Zucker School of Medicine.

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

Annemarie Stroustrup (00:56.278)

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 and I've also in the past been a fellowship director and a medical director so lots of lots of roles in neonatology in my history and I'm also I guess the mother of four and an avid runner what else you want to know?

Misty Good (01:25.687)

That's awesome. That's a lot. mean, certainly we're excited to dig in to all of that and really talk about your just incredible career and congratulations on your recent chair position. That's phenomenal. They're lucky to have you.

Betsy Crouch (01:26.03)

putting so much into this class.

Annemarie Stroustrup (01:41.87)

Thank you.

Misty Good (01:44.833)

Yeah. Well, I guess we'll start by how did it all begin? Tell us a bit about your journey, your background, what motivated you to become a physician scientist?

Annemarie Stroustrup (01:56.928)

sure. I actually, I started out on the scientist track, not on the physician track. So I went to college assuming I was going to study biology because that's what I liked in high school. And my father's a scientist, my younger brother, so was not at the time a scientist, but is a venture researcher. And so I just kind of assumed that was what I was going to do and went through my undergraduate studies and studied molecular biology and bioengineering.

And then went and 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 sort of what route I wanted to take. And while I worked in the lab, which was super fun, you know, it was a very small startup. was the 10th person on site, I think it was, it was, you know, which meant that I got to do everything and everybody did everything, which was, really a fun opportunity. I'm sorry.

Betsy Crouch (02:53.848)

What were you working? What were you working on?

Annemarie Stroustrup (02:57.742)

So the company still exists. It's called Senesys Pharmaceuticals. It was a spinoff of Genentech. And we had sort of Genentech biologists and then University of California Berkeley chemists. And we were doing drug discovery around autoimmune and inflammatory based diseases. So I was looking at the interleukins and TNF and you know, you're looking at small molecule interactions and how to interrupt those with non-injection.

That was the goal of the company. was, and I was in a drug discovery role, sort of doing technology development and then trying it out. was incredibly creative. And, you know, one of those jobs that you shouldn't have coming 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, it was a really wonderful sort of scientific opportunity. you know, it was a job in industry, but we published, it was a very academic group. You know, my only science paper came out of.

my work in that company. And it was really fun to sort of learn and build things and work in that environment in the Bay Area. It was obviously in your neck of the woods. It was really fun. And at the same time, while I was trying to figure out what to do with myself, I'd had a lot of friends from college who'd gone to medical school out of my department. was a, you know,

There was no formal pre-med major. So a lot of the pre-meds ended up as molecular biology majors. And so that had sort of like piqued my interest, but no one in my family was a doctor. I didn't really have much exposure to medicine beyond, you know, as a pediatric patient growing up. And I wasn't a sick kid. So it was, you know, it was just general pediatric kind of stuff. But I got a volunteer job at County General in San Francisco, which I know has been rebuilt since then, but at the time was a very under-resourced.

public hospital in a not great part of town.

Betsy Crouch (04:53.294)

It's still a very interesting, I would say, in a dynamic area of town. And now the Zuckerberg San Francisco General Hospital. Yeah, so it was inspiring to you.

Annemarie Stroustrup (05:00.557)

you

Annemarie Stroustrup (05:06.557)

Yeah, yeah. It was, I mean, it was great. It was, you know, I worked one night a week. You know, that was my first night shift job before becoming an antologist. Well, I had a day job, you know, like, and I didn't want to, I decided I wanted my weekends to be my weekends because I was in my 20s, if that's what you want. And so I worked Thursday nights and in the emergency department at the time, they let me do all sorts of things that like, again,

Betsy Crouch (05:17.07)

Cool. Overnight?

Betsy Crouch (05:25.262)

Yeah.

Annemarie Stroustrup (05:35.458)

looking back, I can't believe that anybody let me do that. But we, you know, reset dislocated shoulders and I assisted with suturing and I did a lot of social management of intoxicated individuals. know, the various things that competent volunteers are allowed to do in a busy emergency room. And so over the course of sort of three years decided that I wanted to go to medical school and that that was

Misty Good (05:51.897)

Good skill set.

Annemarie Stroustrup (06:04.258)

what really drove me in that I probably wasn't cut out to be a bench researcher, but I had caught that research bug and that identification of medical problems and figuring out how to solve them. And so when I was looking at medical school, I was specifically looking at programs that would let me transition into clinical research because I recognized that although some of that scientific thought process overlaps, there's also differences and obviously there's approaches and techniques I needed to learn.

And I ended up in the Harvard MIT Health Science and Technologies 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 (06:47.542)

And why do you think you ended up, I mean, 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 at At the Bench podcast, but I think is also, you know, a really, a really obviously useful skill set and, and, know, has different, has different particular analytical areas. And I don't know, I'd love to hear more about your thoughts on that intersection or the contrast between the two.

Annemarie Stroustrup (06:59.341)

Right.

Annemarie Stroustrup (07:17.004)

Yeah, I think, you know, I had been thinking about sort of basic science PhD programs. You know, when I took my first job and even going into medical school, I wasn't quite sure how I, you know, wanted to make that transition. It became pretty clear to me as I sort of progressed through my medical education and particularly the research program, I was very lucky to get

Betsy Crouch (07:22.338)

Mm-hmm.

Annemarie Stroustrup (07:42.926)

become a part of the HST program had not had a lot of clinical researchers in their program when I got there. I wasn't the first, but it was a majority basic science and engineering program. so the sort of like natural tracks and labs that typically took students from our program were not what I necessarily wanted to do. And I ended up finding Dr. Levine, who was just an amazing mentor, who's a radiologist.

Betsy Crouch (07:47.819)

Mm-hmm.

Annemarie Stroustrup (08:08.334)

And in Boston, obstetric imaging is done by radiology more than it's done by MFMs, as it is in New York. And I know that's a regional difference. And so we worked on the fundamental question of what is fetal MRI good for? You know, was sort of in the early days, you could get reasonable images, but like, should you use it? You know, it's obviously much more of a hassle and much more expensive than ultrasound. You know, when does it really add value? And spent a lot of time

Betsy Crouch (08:14.85)

Mm-hmm.

Annemarie Stroustrup (08:37.006)

scanning pregnant people, looking at the images, figuring out long-term outcomes, and I got to follow those fetuses into children longitudinally, which was really exciting at that point in my career. And I think that that sort of got me, that question of like, when should you do this as opposed to when could you do this, got me interested in statistics. And so that sort of led to the public health epidemiology training. My MPH focus was epidemiology.

Betsy Crouch (08:56.995)

Yeah.

Annemarie Stroustrup (09:06.094)

And so it took me a little while to get to actually the training program because of all the other things you have to do to become a doctor. But I ended up pursuing the MPH while I was a clinical fellow. And it was really out of that, like wanting to be able to understand the mathematics behind those clinical research questions.

Betsy Crouch (09:12.216)

Thank you.

Misty Good (09:28.651)

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

Annemarie Stroustrup (09:58.424)

I mean, I think I've always been very curious in the why, you know, and it almost comes like it's more amazing to think that fetal development ever goes right, considering things have to go right, you know, rather than thinking about what goes maybe a little off track to find out to end up with a child who, you know, has whatever distinction you want to highlight. I think that, you know, in answer to your question, the thing that really got me thinking was when I was, so was a neonatology fellow.

Also pursuing an MPH and the program at Mount Sinai where I trained had an MPH program that met evenings. So that was like very conducive to being a working person of whatever stripe and to get your MPH. But if you're a NICU fellow, you know, your day doesn't necessarily end at 4 p.m. when classes start. And so, you know, again, many thanks to my co-fellows and my fellowship training program for allowing me to like, you know, decide that I wasn't going to take all on Wednesday nights because I was going to take.

class on Wednesday nights and I never did that on a Friday because that wouldn't have been fair. you know they let me spread out the MPH over three years instead of two and so there was only a couple semesters I had to take more than one course and so one night a week instead of being on call I would go to class and Mount Sinai has a really, still has a really 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. And 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. And 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.

And 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. And we all know that neonates have much higher risk of behavioral challenges in middle and late childhood, even early childhood. And a lot of those are not well explained by gestational age or degree of illness in the NICU. And there's not a lot of structural brain imaging that correlates greatly to those behavioral.

Betsy Crouch (12:02.892)

Mm-hmm.

Annemarie Stroustrup (12:21.72)

challenges. And 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.

Betsy Crouch (12:34.978)

You had this inside as a fellow just to point out the vision that you had at that time. That's amazing.

Annemarie Stroustrup (12:38.998)

Yeah. Yeah. So 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 and we ended up soon after I graduated fellowship getting a small project grant.

to look at that question, 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. And 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 gonna answer, right?

Betsy Crouch (13:30.574)

Totally true.

true, right? It's a compliment. Somebody read it first, somebody cared, somebody wants to reach out. Exactly. Yeah, do it.

Misty Good (13:33.849)

Thank

Annemarie Stroustrup (13:38.764)

Right. And so I had the opportunity to meet Russ Hauser, who was working in the Harvard system as an environmental scientist. And he had written a paper about valet levels in babies in a NICU on the South Shore of kind of the greater Boston area. And I called him up and I was like, has anybody ever looked at outcomes? Like I see your papers, I see Antonia Califat, who worked out of the CDC, who had developed a lot of the technologies for measuring these chemicals in urine.

Misty Good (13:39.868)

Yes. Agree.

Annemarie Stroustrup (14:07.352)

You know, 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.

Misty Good (14:15.643)

You

Annemarie Stroustrup (14:17.068)

And I was like, what do you mean? Like, NICUs are great places to do research. It's like a totally contained environment. you know, everybody gets treated with the same, you know, group of pieces of equipment. And, you know, there's all sorts of data. I mean, we have like hourly data on our patients. And he's like, well, you know, the NICU nurses and the neonatologists are real tough nut to crack. So and he said it in the most hot, you know, loving sort of way. But he got really excited. And he was actually ended up being quite a good

Betsy Crouch (14:17.303)

Misty Good (14:37.145)

You

It's bad rap, right?

Annemarie Stroustrup (14:46.614)

to me as well because I obviously was an insider. And 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.

Betsy Crouch (15:06.978)

You have to know that you have to do it during the touch time.

Annemarie Stroustrup (15:09.57)

Right, right, and that it's all non-invasive, right? You can collect your hand on a cotton ball. It's all good.

Misty Good (15:15.545)

It needs to be non-invasive for sure. And then, yeah.

Annemarie Stroustrup (15:18.638)

Yeah, and so that's sort of how I got started. And, you know, and I think that 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, you know, 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 grants applications. And then, you know, there was one more study. you know, and I think that

And that was a collaborative effort with a lot of other people who've been in the field longer than me. And 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. And she never had an R01 funded. There are measures of success in our field that sometimes are a little arbitrary.

Misty Good (16:14.443)

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

Annemarie Stroustrup (16:17.742)

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 (16:28.322)

Yeah, I mean, that is the message, right? Which is that, like, you know, a person is going to have varied success with individual metrics, right? 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, like, as an MD-PhD student for various reasons. And she looked at me she goes, that's comforting. And I thought...

Annemarie Stroustrup (16:53.356)

Hahaha!

Betsy Crouch (16:54.214)

I mean, it's good to know, right? That like, yes, you should apply for an FY 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, know, advancement in your scientific thinking and your hypotheses. But, you know, the F, the K, the R, one should apply for these. But if you get the borough's welcome cams 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 (17:26.67)

you

Annemarie Stroustrup (17:36.866)

Yeah, and the hardest part is like, you know, dealing with those rejections because they're gonna come, right? Like nobody gets every grant funded. And particularly at the beginning, the percentage submitted to the percentage funded is like alarming, right? Like, you you submit 10, you get one funded. And figuring out how to deal with those, you know, with those responses that are negative.

Betsy Crouch (17:41.234)

totally.

Totally.

Betsy Crouch (18:02.285)

Mm-hmm.

Annemarie Stroustrup (18:02.398)

and not taking them personally, but also not ignoring them. I I think that, you know, I have sort of a, when I get the response, if I know it's a rejection, because you typically know that at the time, you know, I'll read it quickly once and I'll get super angry and then do the electronic equivalent of stuff it in a drawer. And then at some point, you know, a little bit of time later, you come back and you actually read it and you're like, you know, they didn't understand this. And you could get mad at the reviewer for not understanding it, but fundamentally, like my job as the writer is to make them understand. And so,

Misty Good (18:16.953)

you

Betsy Crouch (18:25.057)

Mm-hmm.

Misty Good (18:31.543)

It's...

Annemarie Stroustrup (18:31.564)

you know, taking that to heart and figuring out how the next time to be more clear. And especially in the work that many of us do, you know, most of your reviewers are not going to know anything about neonatology. And 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? Like, you know, I'm sorry you don't believe I can get five milliliters of urine from an 800 gram person, but I can.

It's a, you know, and then figuring out how to, you know, internalize that so the next one is better. But that's a hard

Misty Good (19:10.873)

Yeah, I do think it's just, it's similar to, you know, if you're training for a marathon, you know, or something like that. And I try to teach that to my mentees that, you know, you're not always going to get your best score, you know, running track or something every time. And 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, know, you do need to self-reflect so that you can get better.

Betsy Crouch (19:29.518)

She's a need worker. They're all run.

Annemarie Stroustrup (19:29.838)

I'm going to.

Misty Good (19:39.738)

And it's like, but 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, right? And so 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.

We don't get any butter.

Annemarie Stroustrup (20:10.542)

Yeah, and persistence is really underrated. mean, I think that, you know, 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 (20:32.447)

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 (20:42.734)

Oh, I mean, figuring out how to juggle. People talk about work-life balance. I don't know that there's balance. are periods of time where it swings one way and periods of time where it swings another. And 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, you know,

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 and it's really, really hard to say no. And it's really hard to say no.

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 our 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 (22:07.982)

Could I ask one personal question? How do you, as in full disclosure, my au pair just texted me that my son can't find his soccer shorts. anyway, how does one, how does one manage a research portfolio, a clinical role, a leadership role in four children? Just broad strokes.

Annemarie Stroustrup (22:09.933)

Yeah.

Annemarie Stroustrup (22:20.173)

Yep.

Annemarie Stroustrup (22:31.406)

Not always gracefully, I think is the honest answer. And you probably should ask my kids whether or not that's been successful. I think we were lucky when, well, lucky and 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. And we from like,

very, very, 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. know, like it's, we balance that. And if I'm not around, my husband does all the stuff with the kids. And if I'm not around, I do all the stuff with the kids. And at different points during our careers, different ones of us have been sort of more the functional primary parent.

for various periods of time. And 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. And 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.

you know, up and helping with the kids. And so, you know, we have been lucky to have very involved families and even, you know, like my brother-in-law was my daughter's first babysitter. you know, it's, I think we've been lucky with that. And we've had, oh, pairs and babysitters and, you know, 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.

so that, you know, yeah.

Betsy Crouch (24:27.704)

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

Misty Good (24:28.407)

Yeah.

Annemarie Stroustrup (24:37.941)

Annemarie Stroustrup (24:48.814)

So that's not something I'm worried about in your city. But it sounds like a little thing. 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. And I'll be honest, when my kids were young, I

Betsy Crouch (24:52.142)

Yeah, exactly. Although there are comedies in New York City. anyway, yeah, I mean, there's this,

Annemarie Stroustrup (25:17.25)

didn't do anything other than work and children. wasn't like there was, you know, now that they're a little bit older, there's a little more opportunity to, you know, go running every once in a while. But like, you you tear things down when you need to.

Betsy Crouch (25:29.826)

Yeah, but I mean, I think just to celebrate, like, there's this, there are, I mean, you and Brenda Poindexter who have four children, you know? And so I've been, it was, cool to have the opportunity just to ask, to say like, hey, like, you can do it and it can go well, you know, for like the spec, the 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, you know, but maybe we'll stay on the science for a minute. And I'd just love to know what, I mean, what do you think, could you pick?

Misty Good (26:15.257)

It's so true. Yes.

Betsy Crouch (26:25.154)

you know, something from the ECHO study that you feel is like the most compelling that, that, you know, you're proud of and what do you think has to be done next? Or, you know what I mean? That we like, that we as a field have to pursue.

Annemarie Stroustrup (26:43.832)

Right, so I will give a two second background to Echo because you alluded to that. So Echo is the...

Betsy Crouch (26:46.796)

Yes, thank you.

Annemarie Stroustrup (26:54.862)

trying to think of exactly what the acronym stands for, but it's 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, which is like asthma and allergies, positive health, which is something that we don't study so much in science. So, know, what leads to good outcomes as opposed to what leads to bad outcomes and obesity.

Betsy Crouch (27:43.605)

Awesome. I love it.

Yeah, there's an advertisement on my way, like walking up the hill to get to the lab that talks about, like, can we measure blood pressure in terms of joy instead of, you know, the millimeters of mercury, which I like that framing as well.

Annemarie Stroustrup (28:00.234)

Exactly. Yeah, what can we recommend for instead of just recommending against is sort of idea. And 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, you know, children, child environmental health cohorts that have been ongoing for a long time. And we were lucky to be selected to be part of this initially with a cohort of

Betsy Crouch (28:04.844)

Yeah, that's right.

Annemarie Stroustrup (28:28.942)

children born preterm across initially 15 and now slightly fewer than that size across the United States. And then three years ago, we added a second cohort based at Northwell, my current institution, that's just pulling from our obstetric, our general obstetric population, which, you know, our, 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 real...

really interesting place to work. bringing in people from all sorts of backgrounds into the ECHO program. So 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. And 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. And the reason why that's so important is that it led to a study that's actually ongoing that we have two papers under review. So they'll hopefully be available, hopefully, soon.

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. And 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

Annemarie Stroustrup (30:49.76)

specific chemicals they should avoid in our respiratory circuits to impact pollinator development in children and nick use nationally.

Betsy Crouch (30:57.356)

That's what I wanted to know. Yeah, go ahead, Misty.

Misty Good (30:59.811)

was just gonna ask, because there's so many different exposures that one individual, you know, goes, that touches a person, I guess, like throughout their lifespan. And so I'm just wondering if you could, I know you touched on a couple, but talk to our listeners about what are all the different exposures? I know you had a paper on like public water, you know, concentrations of arsenic. I mean, like, but, you know,

How do you, one, 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 (31:39.041)

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. And 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, you know.

there's like 15 different separate species that we measure. And they all, the exposure to those is all at the same time. They're not individual. And 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. And I'll be very honest, the math for that's over my head, but that's why you have collaborators.

Misty Good (32:35.363)

for it.

Betsy Crouch (32:37.676)

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 an Ameris 3D rendering to be

Annemarie Stroustrup (32:48.238)

Ha

Betsy Crouch (32:57.034)

So it's really delightful how much joy you take in your statistics.

Annemarie Stroustrup (33:06.008)

Well, you know, gotta embrace the real world.

Betsy Crouch (33:09.774)

Now I'm thinking of my colleagues, my friends who are also excellent clinician scientists. And it's true, the way that they can, I don't know, 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. Thank you. Thank you for...

Misty Good (33:35.833)

Yeah, we appreciate it.

Betsy Crouch (33:40.078)

Yeah, Ben and Daphna one time were talking about a study and they said, and Ben was like, please not another chart. Like, please a graph, please a graph, you know, and I feel similarly, but you know, those are good numbers in those charts.

Annemarie Stroustrup (33:40.344)

But I think to go back.

Annemarie Stroustrup (33:55.469)

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, 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, know, none of my studies have altered clinical care. This is all observational, right? 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. But we don't actually, you know, I have not done, I don't do clinical trials in the interventional clinical trial model. do observational studies.

Betsy Crouch (33:59.407)

Mm-hmm.

Annemarie Stroustrup (34:25.23)

But then,

Betsy Crouch (34:26.094)

That's why Christy and I are just in awe of your ability. Yeah.

Misty Good (34:27.989)

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 (34:47.47)

Well, and that's the beauty of team science, right? 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. But there's like, mean, there've been 1,200 people at those meetings. This is not stuff I do, right? This is stuff that I know people who do. And then we work together. And the research coordinators really are amazing. The echo.

protocol is a beast. It is hours and 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, you know, and so you know kudos to the families for sticking with it and to the research coordinators who are so engaging that the families stick with it, you know.

Misty Good (35:20.685)

I can only imagine.

Annemarie Stroustrup (35:46.383)

and are able to collect those data and those biospecimens. And then, thank goodness for the biochemists who can measure all sorts of things and all the biospecimens we collect. And 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 of time. And we have really amazing techniques where we can look at all of our biospecimens. There's a...

you know, now amazing techniques developed by a mini sure and his team to look at teeth. And you can look at teeth through development from in utero to when they're shed at age six and see what on, you know, almost down to the day, what certain exposures were. I mean, it's really amazing stuff.

Misty Good (36:29.037)

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

Annemarie Stroustrup (36:40.63)

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

Misty Good (36:49.729)

That's adorable. I love that story.

Annemarie Stroustrup (36:51.662)

And people do. so I think that that's also really the message is that this sort of science takes a really large team. And 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. It's not the whole everything.

Betsy Crouch (37:16.578)

Mm-hmm.

Annemarie Stroustrup (37:18.478)

And then we can go and look at the impact of that on each specific organ development at various different points in development. that's your controlled model. And 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 style, use that one. And it may be two pennies more expensive, but you're not going to create

you're not going to contribute to BPD in these children. It's not the only source. 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 (38:00.12)

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

Annemarie Stroustrup (38:05.166)

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

Misty Good (38:10.797)

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

Annemarie Stroustrup (38:16.558)

Dead animal model is really exciting. We've just started to look at, you know, 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, you know, they're now

Misty Good (38:19.096)

Yeah.

Annemarie Stroustrup (38:45.042)

we recruited over a very long period of time in our cohort. So our youngest kids, stopped recruitment for COVID. We had planned to recruit all the way through 2020 and then the world had different plans. And so our youngest children are turning five or just turned five and our oldest children are teenagers. And so being able to have a large enough number of participants, all who have the same outcome data and the same bio specimens to be able to look at this, you know,

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.

Betsy Crouch (39:18.978)

How many children do you have? Just to give us a sense of the scale.

Annemarie Stroustrup (39:22.798)

so we currently have an active follow-up. I should know this off the of my head, but I don't. It's 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 quote unquote 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 NICHG because the focus is different, but it's still a large enough sample to be able to actually draw some conclusions.

Misty Good (39:54.092)

Amazing.

Betsy Crouch (40:02.636)

Yeah. And 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 (40:13.39)

So there's a couple of practical reasons. Mice are too small to do some of the lung stuff that we wanted to do. And 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. And we have, you know, there's an established rat model of BPD.

Betsy Crouch (40:22.217)

That's fair.

Annemarie Stroustrup (40:41.582)

that we basically adapted with an exposure chamber that Shahana, I would say built, she didn't build it with her hands. She bought the components and got it all put together and the monitoring. And so now we can do inhalational exposures of all sorts that correlate to the preterm period. And 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 building.

Betsy Crouch (40:41.656)

Mm-hmm.

Betsy Crouch (41:01.379)

That's great.

Betsy Crouch (41:07.072)

uh-huh. uh-huh. yeah?

Annemarie Stroustrup (41:10.926)

So it really is just whatever the inhalational ambient environment is as opposed to other components that we know contribute to BPD.

Betsy Crouch (41:18.764)

Yeah, yeah, I mean, I think that we have many, many tools these days, a bunch of different animal models that, you know, have varying degrees of complexity, but also, you know, so considerations for taking care of those animals. Of course, you know, the human microfluidics chips are a hot topic. You know, as a person who's doing some of that, they have drawbacks as well. Some, some substantial ones sometimes.

So, you know, I just think it's worth the, I wanted to know why the rat model, because, you the rats don't have the genetics that we do in mice, but yes, they have major advantages in terms of their size.

Annemarie Stroustrup (41:57.634)

they don't.

Annemarie Stroustrup (42:01.644)

Yeah, and it's definitely a starting point, right? Like this was our first foray, trying to look at inhalational phthalate exposure in a basic science mode. And 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.

Betsy Crouch (42:14.19)

Thank

Misty Good (42:26.775)

That's awesome. That's really awesome. I wanted to pivot a little bit and talk about your leadership journey. And 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.

how they all came about now with your incredible chair roll.

Annemarie Stroustrup (42:57.198)

yeah, I guess, you know, some things, I mean, thinking about how it started, I was, I was a faculty member at Mount Sinai. I was on a K award. was, you know, sort of research track junior faculty. and, our division director had been in the role for a very long time and was headed towards retirement. And 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. Because I had been in a very small division. were, I think, five of us when I joined the faculty right out of fellowship. And so the division director was also the fellowship director, was 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. And so

Misty Good (43:27.393)

No, It's okay.

Misty Good (43:43.127)

my God. I'm tired just thinking.

Betsy Crouch (43:43.266)

Wow.

Annemarie Stroustrup (43:53.657)

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. And 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.

Annemarie Stroustrup (44:17.166)

I don't know that's in my place or yours. and sort of grew the program a bit over that period of time. And 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. And was a, for New York size NICU is 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. And so he sort of told me about the position and the opportunities and it seems like

both a really 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 baby. But also, 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. And so I ended up transitioning over here about five years ago.

And, you know, again, that health system has grown. now 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. And so those have been really fun sort of administrative challenges. The team here is a lot bigger. Obviously, we have, you know, many, many more neonatologists, the neonatal team.

Misty Good (45:59.033)

It's amazing.

Annemarie Stroustrup (46:13.526)

approaching 100 physicians, not quite there yet, and a lot of nurse practitioners and 12 fellows and the whole nine year. So that has been a journey of certainly growth and learning. And then my boss announced he was going to be retiring and so I applied for the job. That would be my other like leadership lesson. You have to apply for the job. These things do not land in your lap, counter to what some people may think. And there were like five rounds of interviews and

Betsy Crouch (46:34.502)

Yeah.

Annemarie Stroustrup (46:43.244)

You know, I was feeling very fortunate to be selected. So that's how.

Misty Good (46:47.16)

That's one.

Betsy Crouch (46:47.464)

And what was it that piqued your interest?

Annemarie Stroustrup (46:50.284)

about the chair role. So at Northwell, it's a really interesting position because there are, as you mentioned at the beginning, there are a lot of titles. There's the academic title and then there's the health system title. And those really are distinct but complimentary roles. And 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.

Betsy Crouch (46:58.466)

you

Annemarie Stroustrup (47:18.338)

And that's kind of a fun challenge, right? 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. And I still have my research. Like that hasn't gone anywhere. As I said to my research team, like this is the one part of my job that's staying exactly the same. And I am so grateful for that.

Misty Good (47:37.773)

That's awesome though, to be able to like, you know, do all of it.

Annemarie Stroustrup (47:42.572)

Well, we'll see. mean, I'm like, you know, six weeks in, so.

Misty Good (47:48.353)

No, it's amazing. I'm sure you have an incredible team to help.

Annemarie Stroustrup (47:52.419)

Yeah, yeah, no, and 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.

Misty Good (48:05.625)

That's great. Well, congratulations on all of your success.

Annemarie Stroustrup (48:09.24)

Thank you.

Betsy Crouch (48:11.502)

Do 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. I have to confess that your pediatrics article this year on a Delphi approach in consensus recommendations for sustainable and equitable neonatal staffing, I have never heard of that term.

Annemarie Stroustrup (48:37.409)

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. Honestly, they're work products. 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

Betsy Crouch (49:04.226)

Yeah.

Annemarie Stroustrup (49:05.922)

has not sort of explicitly codified what a job is. And that comes out of the days when there weren't enough neonatologists. So every hospital hired a neonatologist to cover their delivery service. And that person eventually was able to hire a second person because there was a second trained person. And I know when my first job, I was hired just

under the work schedule of all the work divided by the number of people we have. Like that was, and that was, that was the model, right? That was the common model. And so if you were lucky, lucky to be hired by, I was hired by a group, I was the fifth person hired and the boss stopped working weekends. So we worked one and four weekends and you know, we split the call pretty evenly. And you know, I got a little bit less service time because I had a research career, but like, you know, was, that was how it was done. And that was true for everybody, whether you were in a group of two or a group of

15. And 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 a 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. And that has a lot to do with combating burnout and a lot to do with patient safety, actually. If you don't really want to be taking care of your child for 48 hours straight, that's not good for anybody. And 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. mean, there's a financial cost to this. And health systems don't always want to hear that.

Betsy Crouch (50:49.048)

Mm-hmm.

Misty Good (50:51.789)

I was going to ask because I think that's one of the biggest issues, right? That 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. And you've done a lot of work in that regard to help standardize that. And 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

news, 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 (51:35.361)

Yeah, mean, think, you know, 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, like the economics don't really make sense to do what we do. And the way that health care is financed in the United States is just, you know, fundamentally, fundamentally and systemically broken. And 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. And I think that senior administration certainly, my institution, senior administration is hard in the right place. I know that. And I don't know that

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. And this has been for a while. This isn't like a last two years phenomenon. This is quite a long time in coming. And 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. And I also have to balance the budget.

And sometimes those two things are diametrically opposed. And so you do your best to figure out a middle way. So the budget's going to be close but not perfect. And the faculty are going to be OK but not as happy as they could be. And 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. And we have to make sure that that's our priority. That's my view.

Misty Good (53:23.577)

It's a great view, great perspective.

Betsy Crouch (53:27.17)

Yeah, thank you so much for doing that work on our behalf.

Annemarie Stroustrup (53:32.002)

Yeah, but it is, it's a neonatology problem, but it is an everyone problem. I think that, know, saying that we're special or unique and the only one's having this problem is totally untrue, but not acknowledging that it is a problem is also, you know.

Betsy Crouch (53:47.788)

Yeah, exactly. I find 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. And also saying, if one's, back to your persistence quote, but just to say that keep going.

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. Struestrup. 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.

Misty Good (54:41.923)

Take care.

Annemarie Stroustrup (54:42.905)

Thank you.