#479 - When a NICU Physician Group Is Replaced, a First-Hand Account

Hello friends 👋

On July 1st, nine neonatologists at the only Level III NICU in Southern Oregon were terminated and replaced with a locums-only staffing model. Dr. Shelly Haug Monti, one of those physicians and a founding member of Babies First, joins Ben to describe what happened, what the group had been trying to raise with hospital leadership beforehand, and why they chose to organize rather than quietly move on. She discusses continuity of care in a 32-bed unit covering 20,000 square miles, what meaningful physician voice in staffing decisions should look like, how the group engaged nurses, families and state legislators, and how clinicians anywhere can recognize the early signs of a deteriorating healthcare system.

Learn more about Babies First here: https://www.babiesfirst.org/

Link to episode on youtube: https://youtu.be/ib-hHj8zZPA

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

Ben Courchia, MD (00:00.728)Hello everybody, welcome back to The Incubator Podcast. We’re back today for a special episode, and I have the pleasure of having Dr. Shelly Haug Monti in the studio with me. Shelly, welcome to The Incubator Podcast.

Shelly Haug Monti, MD (00:11.143)Thanks so much for having me. I appreciate it.

Ben Courchia, MD (00:14.070)Of course. You’re a neonatologist and a founding member of Babies First, an advocacy group based in Southern Oregon. Your story really came to prominence over the summer. You’re one of a group of nine neonatologists who were terminated from their practice at a hospital in Southern Oregon on July 1, and that has drawn a lot of attention online about what it means, especially since you were all replaced, mostly by traveling clinicians, and what that means for the care of the babies there. So I appreciate you taking the time to come on the podcast and talk about this.

First of all, for people who haven’t watched Dr. Glaucomflecken’s video on this topic, I highly encourage you to check it out. He did a very nice job. But I really wanted to chat with you specifically about how this felt as the story was unfolding in real time. In the months, and even years, before July 1, was there anything in the unit or the hospital that led you to believe this change was coming?

Shelly Haug Monti, MD (01:43.796)Yes, I think we were concerned for quite some time. Like everyone else in your audience, we’ve spent our careers trying to care for some of the most vulnerable human beings imaginable. We learned pretty early in our careers that our patients’ survival and long-term outcomes depend on far more than the expertise of a single physician. So we wanted to be advocates and a voice for our patients when we saw hospital administration making decisions that directly affected patient care, and we kept speaking up. We had pretty frank conversations as a group of nine: “What’s the worst that could happen? It’s not like they’re going to fire us all, right? We have to stand up for the teamwork and the protocols we’re putting in place.”

So we were really surprised. I can’t speak to the hospital’s motivations, but we were really surprised when they unilaterally decided to terminate our entire group of neonatologists and replace us with temporary locum physicians and nurse practitioners.

Sure, part of it was concern about losing our jobs. But we’re all highly employable, skilled physicians. The more we sat with what happened, the more it motivated us. It wasn’t the loss of our jobs. It was the loss of years of institutional knowledge, the established relationships, the clinical infrastructure our team had built, and the vulnerability of our specific patient population.

Shelly Haug Monti, MD (03:57.387)It became really clear that a hospital can fill every shift on the schedule and still profoundly disrupt the system of care behind it, without the community ever knowing, and without the physicians at the bedside having any voice in the outcome. So we felt we had a choice. We could walk away, move on, and focus on rebuilding our careers. But we couldn’t reconcile spending our careers advocating so fiercely for individual babies at the bedside, then staying silent when we believed the very system caring for those babies was at risk.

So we all took a leap, did something we never envisioned for ourselves, and became advocates on a different stage by founding Babies First of Southern Oregon. It began as nine physicians raising concerns and grew into a movement that brought together families, nurses, physicians, and community members, and then grew even bigger, to state legislators. We’re working to protect exceptional neonatal care, demand transparency in decisions that affect patients and the communities these hospitals serve, and ensure physicians have a meaningful voice in the systems we practice in when they’re reshaped around us.

I’ve said a few times that I used to think my greatest responsibility as a neonatologist was to the vulnerable patient lying in the incubator in front of me. That’s still true. But sometimes, to protect the baby in front of you, you have to be willing to stand up for the entire system surrounding them. That’s how I unexpectedly became a physician advocate.

Ben Courchia, MD (05:53.006)Very interesting. For listeners trying to put themselves in your shoes, how big was the NICU (neonatal intensive care unit) you worked in, and what kind of census were you dealing with day to day?

Shelly Haug Monti, MD (06:05.620)It’s a level III NICU, the only one in Southern Oregon, covering over 20,000 square miles, including very rural areas of Southern Oregon and Northern California. Our catchment area stretched all the way to the Oregon coast and well inland toward Idaho. It was huge. If that NICU has issues, the next closest NICUs are several hours away. Sending a baby who needs cooling from a small community four hours north was a huge ordeal for our community to even think about. I don’t say that as a scare tactic. The NICU is still open. What we’re trying to communicate is that just because the shifts are filled and the beds are open doesn’t mean the same excellent team that was built is still there.

Ben Courchia, MD (07:25.913)I’ll get back to that in a second. How many beds were you covering in that NICU?

Shelly Haug Monti, MD (07:34.249)It was 32 beds, about 10% of Oregon’s NICU bed capacity.

Ben Courchia, MD (07:45.850)I think the question really being asked is whether this story highlights what’s at stake, which is continuity of care for neonates in the NICU, versus an ER model, where infants who are there for months at a time see a different physician every day.

Shelly Haug Monti, MD (08:18.523)Right. I think continuity isn’t a luxury in the neonatal intensive care unit. It’s part of the safety infrastructure we build. The schedule can be filled with qualified names. There are many qualified neonatologists who also do locums, and we’re definitely not pointing fingers. Locum physicians are an important part of medicine. What we’re advocating for is transparency to the community when those staffing decisions are made, and a real voice between hospital administration and the clinicians at the bedside, because it seems we’ve really lost our voice. If physicians can raise safety concerns but those concerns have no meaningful path to influence a decision, then it’s not a true physician voice. And if speaking up will cost us our jobs, you don’t have a culture of safety. We’re losing physician autonomy. As medicine changes across the nation, we’re increasingly asking physicians to carry responsibility for outcomes while giving those same physicians less influence over the system producing those outcomes.

Ben Courchia, MD (10:08.720)Do you think the conversations you were having with the hospital before it decided to overhaul the NICU’s staffing model led to this outcome because they weren’t a two-way street, or broke down? Or did anything else play a role, in your opinion?

Shelly Haug Monti, MD (10:36.861)I do think there was a loss of understanding and a disconnect between hospital administration and the concerns we were trying to voice. We didn’t really understand the governance structures in place, or what happens when you can’t talk directly to the people making staffing decisions about important educational roles. How do we maintain a level III NICU if you take away our NICU educator role? How are we supposed to care for 23-week, 400-gram infants if our nurses are uncomfortable at the bedside because they’re losing that valuable education piece? So we felt it was our responsibility to keep speaking up. But it always felt like it came after a decision was made, which isn’t a true voice. Being told a decision has been made is different from having someone at the bedside say, “This decision you’re making concerns us.”

We understand that hospitals have to operate within financial constraints. But that shouldn’t conflict with maintaining excellent bedside care. Our goal isn’t to tell hospitals how to run their businesses. We want to make sure their business decisions don’t happen in a vacuum, because patient care is at stake. This isn’t like every other business making a decision. Physicians don’t want to run hospitals alone, but we want to keep a meaningful seat at the table.

Ben Courchia, MD (12:25.380)That makes a lot of sense, obviously. How has it been for you since July 1? You mentioned the catchment area. How have you navigated this new chapter? Did many of you have to move? Did you transition to other jobs, or to general pediatrics? I’m curious what that looked like for you as a group.

Shelly Haug Monti, MD (12:59.277)As a group, we looked at the market, and unfortunately that’s the only NICU in the area. We weren’t offered any way to stay, whether to help with the transition or to sign back on under new leadership. We’ve been asked, “Why didn’t you stay? Was there some middle ground?” But that wasn’t presented to us as an option. So we had to look at moving. Some of our group decided to stay for a while, because we’ve all built our lives in this small community, and they’re working locums. So again, we’re not against locum physicians where they’re needed. About half of us have moved on to other jobs. One thing I was really looking for in my next job was a place where my voice as a physician advocating for my patients is appreciated and heard, and I feel like I’ve found that, hopefully.

Ben Courchia, MD (14:21.422)Is that still in Southern Oregon?

Shelly Haug Monti, MD (14:24.071)No, I moved to Arizona. Several of us moved out of state.

Ben Courchia, MD (14:34.042)Interesting. I hear in what you’re saying that there’s no animosity or ill intent toward locum physicians. I think they serve a very real purpose. But what you went through raises an interesting question: is there a point at which reliance on locums can lead to unintended consequences in caring for babies who require some form of continuity? Understanding a baby’s course, and making decisions based on a long hospital stay, is a critical piece of the puzzle in neonatology. So that’s obviously a big deal. How are you using the organization you created, Babies First, as a platform for advocacy, and where is it taking you, so others can learn from your experience?

Shelly Haug Monti, MD (15:40.139)In building Babies First, even those of us who left the community felt compelled to keep advocating for it. As we built the platform, we started hearing from more and more physicians, in other disciplines at the same hospital, across the state, and then nationally, even in other specialties. We focused the platform on a few areas. One is community education, to push toward transparency. That has included education on our Facebook advocacy page about what different levels of NICU do, what happened, and what it means for the community. We’ve also done local media outreach and organized physician advocacy within the community, to help the physicians who are still there have a voice.

We also wanted to use the platform to collaborate with other advocacy organizations: local physician groups, the Oregon Nurses Association, the local medical society, and state medical chapters. Then it grew bigger than we expected, and we found we could actually have an impact on legislation. We started meeting with local and then state legislators. One of the biggest lessons we learned was how approachable legislators are, and how much they want to help protect their constituents, with ongoing discussions about governance and legislative protections. We haven’t seen the fruits of our labor on the legislative side yet, but we were surprised that this became an avenue for us.

We’re seeking policy changes that encourage stronger local hospital governance and accountability, meaningful participation of physician staff in major decisions, and straightforward transparency around changes to essential clinical services in these communities.

Shelly Haug Monti, MD (18:00.878)We want accountability and transparency. Consultation after a decision is already made isn’t a meaningful physician voice to us.

Ben Courchia, MD (18:09.701)For people who want to learn more about Babies First, I encourage you to find the group’s Facebook page. If you search “Babies First Advocacy” on Facebook, which is how I found it, you’ll get to it. I saw that you recently posted that this became a point of discussion at the recent gubernatorial debate in Oregon. So it’s definitely a topic that resonates not just with your team, but with the public, and it’s becoming a subject of attention and concern. That’s quite good.

We’re running short on time, and I have two more questions. First: do you think what you went through is unfortunately a singular event, or potentially a symptom of our health care system, something people far outside Oregon should be on the lookout for?

Shelly Haug Monti, MD (19:21.855)Great question. Yes. For lack of a better analogy, one I’ve come up with is that we’re a canary in the coal mine...

Ben Courchia, MD (19:35.120)In the coal mine.

Shelly Haug Monti, MD (19:53.439)...but much deeper in the coal mine, because of the vulnerability of our patient population. So I do think this is a warning of systemic issues. We’ve heard stories from across the nation, from other specialties, emergency medicine, hospitalist groups, and anesthesiology groups, that this has been happening to them, and now it’s starting to happen to neonatology groups.

So I think we need to take this as a warning sign. Just as we learn to recognize a deteriorating patient, physicians need to start teaching each other to recognize a deteriorating health care system, and what we can do about it. One step is understanding your hospital’s governance structure: who makes your clinical staffing decisions, and who sits on your board. Look at your bylaws. Can you actually communicate concerns to them in a meaningful way? If a decision could compromise care, what mechanisms exist for you to challenge it? You want to be in a culture that supports that communication.

I also think it’s important for physicians not to underestimate how much people outside the physician community care about this. We don’t have to advocate alone. Build relationships across disciplines, with other professional organizations and with your community, and start talking about concerns clearly and factually, through the lens of patient care. Communities care. NICU babies are really the most vulnerable patients in our communities, and when you start talking about changes that affect people’s babies, they care. Physicians are extraordinarily good at identifying clinical problems, and we need to get better at translating those concerns into effective systems-level advocacy.

Ben Courchia, MD (21:28.907)I couldn’t agree more. You kind of answered my second question in that answer. But my last question for you: as neonatologists, and physicians in general, we’re so absorbed by our work and our patients that we sometimes don’t get the chance to lift our heads out of the sand. What did this experience teach you about yourself that you didn’t know before?

Shelly Haug Monti, MD (22:08.752)That physician advocacy doesn’t end at the bedside. Protecting your physician voice means protecting the patients who depend on us. That doesn’t always look like changing the pressure you’re giving a baby in septic shock. It can also look like having really hard discussions with your hospital administration about the financial cuts that need to be made, and where. I think the biggest message we want to get across is: don’t wait until your team disappears or is taken away from you. Understand how your hospital makes those decisions, and start advocating for systems and communication that keep that exceptional care in place.

Ben Courchia, MD (23:04.358)It’s interesting, because the way you describe it sounds almost like sepsis. If you can get ahead of the curve, prevent it, and watch for the signs and symptoms, you have a much better chance of treating the problem than if you find yourself trying to play catch-up after the infection has spread. I think that’s a very powerful message. Shelly, I appreciate you coming on the podcast to share your experience. It was very valuable. Thank you for your time, and best of luck in your new chapter in Arizona and with the work you’re all doing with Babies First.

Shelly Haug Monti, MD (23:43.211)Thank you. I appreciate you.