Bio: Dr Jayasree Nair is a Clinical Associate Professor of Pediatrics and Program director of the Neonatal Perinatal Fellowship program at the University of Buffalo, and attending neonatologist at John R Oishei Hospital, Buffalo.
After medical training and Pediatric residency in India, she completed her second pediatric residency and neonatology fellowship at the University at Buffalo. She then joined the Department of Pediatrics as a “Buswell” research faculty studying the effect of transfusions on mesenteric blood flow and reactivity. She is a physician scholar and educator combining her passion for improving clinical care, education and mentoring pediatric and neonatal trainees while continuing her research interests- in neonatal resuscitation and necrotizing enterocolitis. For her translational research on neonatal resuscitation, she has received grants from the American Academy of Pediatrics and the NIH-NICHD. She is involved in regional and national pediatric organizations, currently including the roles of Chair, Planning Committee for the Eastern Society of Pediatric Research and Chair- Student, Resident and House Officer Awards Selection Committee at the Society for Pediatric Research annual conference.
The transcript of today's episode can be found below 👇
Ben 0:45
Hello, everybody. Welcome back to the podcast. It's Sunday Daphna. How are you?
Daphna 0:51
I'm doing I'm doing well. I'm doing well. I love interview days. So yeah, it's an interview day.
Ben 0:57
So I think it's it's the first interview of the month of July. So we should let people know that this month is dedicated to trainees and people in medical education. We're having a great lineup. And we're starting off today with Dr. Nair from the University of Buffalo. And she is the fellowship program director there. And so we're very excited to talk to her. And next week, we'll have on our row Pro Annual, who's a resident going into fellowship this year. So we'll talk about the life of a resident and yeah, and and we have a lot of other stuff coming your way. So we're very excited to be able to dedicate a few episodes to training and trainees. Yeah, so
Daphna 1:47
so people should share with a new trainee
Ben 1:50
of Absolutely, absolutely. Another cool episode that we will release, is it are we releasing this week definitely going to pressure me to release this week. Absolutely. tight tight window for me, but that won't make it happen. So as as most of you are probably aware, in the US and maybe even outside the US the recent decision to overturn Roe vs. Wade, which really impacts access to abortions in the US has really shaken our country here. And there's a lot of things that are going to impact the practice of neonatology one way or another. And so we are very excited to be able to have on the podcast, Dr. Dr. Jonathan fanaroff, who is a neonatologist, as you probably know, and who also has a law degree, and who will talk to us a little bit about the implications of this decision by the Supreme Court of the United States. And what does that mean practically for us on the ground as neonatologists we strongly believe that if you are interested in the impact of this decision, on a broader level, you will find many outlets where experts have talked and discuss the issue. But we wanted to do this for neonatologist and for the people working in and around neonatology. So yeah, we're very excited this this episode should come out. I want to say Wednesday or Thursday, depending on how quick I can be with the computer.
Daphna 3:32
But we think it Yeah, we tried we were trying to stay, you know, with just in time topics for you guys as they arise. So
Ben 3:41
and it's, it's interesting to realize how clueless you can be sometimes about a topic, right? I mean, these are things that we didn't tend to have to think too much about. And now suddenly, we're faced with the idea like I went to I actually know about this from from a law perspective, from an ethics perspective. And and we could always, always tend to learn more, so we're happy that we're able to put this episode together. Okay, so without further ado, today, we're excited to have on the podcast Dr. Jayashri Nair, who is the clinical associate professor of pediatrics and program director of the neonatal perinatal Fellowship Program at the University of Buffalo, and attending Neonatologist at John R. O'Shea Hospital in Buffalo. After medical training and pediatric residency in India, she completed her second pediatric residency and neonatology fellowship at the University at Buffalo. She then joined the Department of Pediatrics as Buswell research faculty studying the effect of transfusions on mesenteric blood flow and reactivity. She is a physician scholar and educator combining her passion for improving clinical care education and mentoring pediatric and neonatal trainees, while continuing her research interests in neonatal resuscitation and necrotizing enterocolitis for her translational research on neonatal resuscitation, she has received grants from the American Academy of Pediatrics and the NIH and Achd. She is involved in regional and national pediatric organization currently, including the roles of chair Planning Committee of the Eastern society of pediatric research, and chair students, resident and house officer awards section committee at the Society for pediatric research annual conference. Guys, let's welcome Dr. Nair to the show. Jesse, thank you so much for being on the show with us this morning.
Unknown Speaker 5:35
It's my pleasure to be here. Thank you so much for the invite man, of course.
Ben 5:38
So for the people who may not know you, you are a neonatologist. You are a fellowship program director at the University of Buffalo, you are a wife, a mother, you have many many, many roles. Can you tell us? Am I Am I forgetting anything? Or is there anything else that you wanted to add to the list?
Jayasree Nair 6:03
I almost feel like I'm a community pediatrician to all my my my community people as well. And that's not necessarily a role either that I've trained for, especially in the last 10 years when we focus on unit ology, but it came up so much during COVID. It's amazing. That role was not, you know, something that's on my resume, right? It's very much in use right now.
Ben 6:28
I have my brother who sent me a picture of his son after a BCG vaccination, who developed like a little swelling. And I was like, Man, this has been a while since I have even considered these types of issues. So I can feel the like the phone calls you get from the community reminds you of like, oh, man, I haven't done this in a while.
Unknown Speaker 6:50
Absolutely, absolutely. Can you
Ben 6:53
can you tell us a little bit? What was your path like to get to becoming a neonatologist that you are today? I know, I know. You're trained in India. I know, like many IMGs. We talked to Dr. Salas last week about img is doing double residencies. But I'm just curious as to what is the path that leads you to a career in neonatology?
Jayasree Nair 7:16
Absolutely. So you're right. Actually, I did listen to Dr. Salas interview, and I identified with so many of those of the points he brought up as an img. But at the same time, I feel like every every step in that path was meant to happen because it finally made me who I am. And you know, sometimes I feel, I feel confused about all the things I feel passionately about. And then you look back at your story, and you understand why you feel so passionately about those things. So when I started out in India, it was purely clinical, you you go to medical school, I wanted to be a pediatric surgeon. That path seemed too tough. And then I realized that the pediatrics was the bat that I really liked out of the pediatric surgeon. And so I went into pediatrics, but then wanted to do more, sort of more procedure based specialty. And I knew I wanted to be a neonatologist in India, but there weren't too many options open for a super specialization as a disc called or a DM. In India, there's very restricted spots. But I did work. I worked as a pediatrician for a year I did most of my time in the NICU because nobody wanted to do time in the NICU. So you know, it was it was basically just just all hands on deck, there were 5200 deliveries a day, there will be these pouring in from everywhere. We did multiple exchange transfusions united, it's sort of like being in a medical camp every day of your training. And that's where I did my residency in India. So there was really no time to think and there was no time to focus on ventilation and the next steps, it was basically survival and then you move on. So when I did practice for a year after it was a much better private hospital setting where I got introduced to a lot of neonatology activities that we actually do here, you know, high frequency ventilation, putting in lines, sort of sustaining these Infants who are born preterm. That was a nice segue into coming to the US, which really was in my other role as as a as a wife because my husband matched here and I came over while I was and had my son soon after, so I actually stayed out a year while I took my steps and then got into residency and the second residency it was a shorter residency but
Ben 9:33
a residency nonetheless. Right.
Jayasree Nair 9:35
Residency nonetheless. Exactly. And I want to offer this relative Yeah, I wouldn't say it was a cakewalk, but it really wasn't. I mean, the the academic part sure, because we had a rigorous training in pediatrics, that part was okay, but it was a totally different system. Expectations were different. You know, and it really did help me in focusing on the other aspects that I had missed out in my first read. didn t which was stepped back let someone else do the active procedures like I spent my whole first year in Indian in India, in my residency just putting in IVs. Doing LPS doing bone marrows. It was literally like a procedure room that went on for the first year. So this, this really helped, like set settle back in and focus on what are we aiming for these kids? Let's think more. What's the next step? So I don't want to say that it didn't help me at all. It really did.
Ben 10:28
Let me go back to India. Is it true that you were contemplating a job as a teacher when you were a kid?
Jayasree Nair 10:34
Yes, it was. That's what I wanted to be forever and ever. I thought I wanted to be happy. I am a teacher I do. My goals. So I love it. I actually went as you know, for career day in my son's Middle School, when he was in, in seventh or eighth grade. And I said, Isn't this fantastic? I wanted to teach and I wanted to be a doctor and I did both. So this is this is great. So I do think that neonatology offers that that kind of, I guess, options for for you to do multiple things to do research as well. I didn't want to do that. I have that curiosity. But it gives you a little chance to do a little bit of all three.
Ben 11:17
Well, it's funny you say that, and I was hoping you were gonna say that. Because technically, in Europe, we are taught that the word doctor comes from the Latin that says teacher, so technically, a physician is first and foremost a teacher. So I'm glad that we we arrived.
Jayasree Nair 11:32
Exactly, absolutely. And it doesn't have to be academics, you can find it strategic everywhere. There's always a willing listener.
Daphna 11:41
Yeah, I find that the Nikki was specially has this opportunity. Because we, you know, we especially if we do some academics, you teach alert learner as you teach your nursing staff, but but we're teaching parents so much about their infants and about how to be parents. That it's a really neat opportunity.
Unknown Speaker 12:01
Absolutely. I completely agree with you.
Ben 12:04
I wanted to ask you about your role as as so you are a neonatologist, and I'm very interested. You're the first, I believe, program director that we have on the show. And I am wondering, how did you become a program director? I feel like a lot of the people I speak to who are program directors, either partially went wanted to go into this and got pushed the rest of the way. But I'm wondering in your case, was that something you always strived to reach? And what was the story behind you reaching that position?
Jayasree Nair 12:36
Oh, that's a lot of pressure, saying that I'm the first program director or now I have to maintain standards, right. So truthfully, I think I think you're, you know, I always wanted to be in education, residency, education, fellowship, education. I'm skipping out on a big part of the being IMG, which is sort of what you do. As you graduate from fellowship, you have very limited career options in the type of job that you can get for the visa you're on and the long path it takes to get to a point where you feel like you have a choice. And I think I'm at that point now that I actually feel like, oh, I have a choice in where I can go. But I didn't try it out a fellowship, it was like I had to, I had a lot of procedural things to do that I needed to get checked off. So I started my career as a researcher in a research track, I needed to get a lot of publications, and I actually really enjoyed research, I found the perfect mentor during my fellowship, he continues to be my life mentor, as well, even from many, many miles away. But at the same time, it really did set me up for for a career that will always have some aspect of research in it. But at that point of time, fellowship, education was something that I wanted to do, just because you know, every fellow graduates has ideas on what they want to do. But there were many people ahead of line where I was, and so it was something that was sort of on the back burner for a while. And I had the pleasure of being in the same program that I did fellowship. And so I sort of knew the history of the program. And when there was an opportunity that came up. Everybody knew that I had been wanting this for a while. Okay. And and the fellows, actually, I think it was the fellows that actually pushed it was in the sense that they really wanted me to take it on. So I went in, I loved it. I knew this was what I what I wanted to do. And I went in completely into it. And then COVID happened and I felt like I had no preparation whatsoever. At the same time. Mind you, like many other program directors, I had no educator training. I had no leadership training. These are things that we are recognizing now as neonatal perinatal program director community that these are things that that should happen at some point during your fellowship and early career years, but they don't So
Ben 15:00
how long how long have you been program director before the pandemic officially started? I guess in 2009
Jayasree Nair 15:05
months, I think I want to say I, like took over in July of 2019. That was my first sort of recruitment year, there were things that we wanted to see change. You know, there were there were a lot of environmental change that had happened here as well, as well as the change in personnel in leadership roles. So that, you know, I was coming into that role trying to figure out what my next step, next three years would look like. And I had a plan, I had a plan on what I wanted to see. And then March of 2020, COVID happened and all of a sudden, I became a videographer. I learned how to use Zoom. I said, so
Ben 15:46
we will get into that, because I think there's a lot to discuss there, especially from a healthcare standpoint, and also from a an educational standpoint. I think it's very interesting, right? That what you're what you're describing in terms of, of taking on this role, and some of the of the, of the deficiencies that every program director enters the job with, because we are not being trained in like you said, Education Leadership. I also wanted to touch on the fact that like, if for our American colleagues, like you do not understand the the journey of h1 visas versus j one visas and the potential for just being shipped back and kicked out of the country. Like this is something that many people are not familiar with, and that probably deserves a whole episode. But going back to becoming a program director, I'm wondering what, as of today, what do you perceive are the biggest challenges facing most program directors around the countries who are leading a fellowship program in neonatology?
Jayasree Nair 16:53
So I mean, you know, it's funny you say that, because we sort of got together during COVID. And we published a whole series of articles that got in the Journal of Perinatology. about the challenges that are facing the program's, I think every program director has unique challenges, because it depends on the environment, it depends on the size of your program, depends on the strength of your program. I mean, the first thing I think about buffalo is Oh, my goodness, people are not going to come here for the weather or the city, right? It has to be other things that I'm showing them. It's always a big deal, because it's always nobody's going to just no resident in California is going to say, Oh, let me go to Buffalo. It sounds like a good a nice city to be in. So I think besides the overall landscape, and unfortunately, neonatology is one of the specialties that is not at risk of not having applicants, I'm married to a pediatric endocrinologist and I call him the dying breed, because I think there are not many people waiting in line to take over from them. And that's a sad financial reality. Again, a whole other episode for you on why some of the specialties are going to just sort of die out because of the remuneration and because of the financial aspects, and people don't, the trainees don't see it as a viable career option. But neonatology, fortunately, has not had that problem, right? There's always people wanting to take this on. And again, some amount of this is probably financial, because it's one of the better paying specialties in pediatrics. So you'll always have people who want to come in, but the bigger programs attract a lot of their own graduates. They have more resources. So I think the challenges are specific to the size of the program that you're in the smaller ones, the mid level ones, and the larger programs all have different challenges. And, you know, the smaller and the mid level ones, it starts from actually, what are we able to offer, offer the candidates? Are we going to fill our spots, and then into how can we make this better? What What can we do to make this education better? And yeah, so they're very unique. I don't know that I can answer all of it together.
Ben 19:07
But so then I want to challenge one of the points you made. You said where neonatology is not really at risk of seeing an issue with applicants. But on the other hand, we're seeing a trend nationally where residents are getting less and less exposure to the NICU maybe like a month a year or something. And it's very concerning, because it gives less, at least gives less opportunity to people who are not sold on neonatology from the get go to fall in love with a specialty and I've spoken to many residents who say bye yeah, kind of like neonatology. But basically, the timing was not right, because by the time it was time to apply, I had only rotated once and I wasn't sure. And so I'm wondering if this new trend in reducing the exposure of the residents to the NICU is our is something you're seeing translate into less applicants than before in neonatology even if we're not at risk to be, like you said, like pediatric endocrinology where err, it's been documented that doing a fellowship is financially the wrong decision because you will lose money over the long haul. So it's very difficult to justify that for people who have loans and other commitments. But if even if we're not there yet, are you seeing a change? A change? That's at least decreasing the number of applicants?
Jayasree Nair 20:20
Yeah, no, absolutely. You bring up a good point. I mean, there are threats, no doubt, it's not I think I what I meant to say was relative to other specialties, neonatology is safe. There's definitely threats for any fellowship, you know, to justify the three extra years of training in terms of, are we seeing it in numbers? I have to say, because of COVID, we really don't know the answer. Because what happened with virtual interviews that came up during COVID, is that everybody applied everywhere. So we actually saw we used to get 2025 applicants, and we got 60 applicants last year. I mean, reading through it, I don't know how many were serious. I think everybody was applying everywhere, because it's a little more equitable, I think, to be able to do virtual interviews, right, you don't have to think about the expenses associated with going to a place. And then some may be actually interested, we did get candidates who I felt were really interested. But a lot of them were probably it was the fear, the fear that they wouldn't match that everybody applied everywhere. So I don't know. I think overall, if you look at the trends that were released in the match, the applicant number has sort of stayed steady, but gone down a little bit for sure. There's no doubt about it I, however, it is reality, also that most neonatal programs do end up matching. And that's Edie knew, I think critical care and cardiology are the few that really always will end up matching. So one way or another, there were maybe seven seats that were weakened this time, but there were a few candidates who also would have gone outside the match. So number of people going down is probably probably true. The residents, I completely agree with you, I am sort of beside myself with how little exposure, unfortunately, the residents are getting in the NICU. And some of it is related to another point that I know we were going to touch on later, which is another threat, if you will, or it's a necessary threat to the Fellowship, which is the added, you know, people we have helping us in the NICU. So the APs are an integral part of the NICU. Now, we can't imagine a NICU without them. But it is definitely affecting both resident and fellow education. And at any point of time, we find ourselves discussing how to make this better. And I feel like we've had this discussion every year in the last 12 years or so that I've been in neonatology and no one has the right answer to it yet. So definitely resident education is suffering simulation may be trying to get them to do we we've tried to get all our residents who are interested in the NICU to do an extra sort of elective rotation where they just do procedures, transport, they don't do the normal, you know, writing notes and things like that, but they just do the exciting things, going to deliveries going on transport, just to build this up just to try to get this interest back. But I'm, I'm open to any suggestions. I mean, we talk about this all the time.
Daphna 23:16
Well, that was you know, from somebody, especially like you given your training and how many procedures you were able to do before, you know even your fellowship training. It's it's much leaps and bounds different from what a typical us trainee gets, which is good for the babies. Right? That means that we're having to do less procedures, and like you said, a lot of it is sharing those procedures. How do you think that will impact neonatology long term?
Jayasree Nair 23:47
Yeah, I I don't want to say we'll forget to do intubations right, we will always find a way to do it. But there is this dependence also, which is happening at the same time on on equipment. So we have video laryngoscope is that are more available, right technology is also rising at the same time. So I think we will always find a way to work around it. We are moving away from integrating everybody in the delivery room. We're not doing meconium you know, aspirations in the Dr. So of course the procedures are going down. But it's it's very tough. I think a lot of the programs now including ours is focused on simulation even to just get them give them an idea because we can't really have people have multiple attempts or multiple tries. Everybody is focused on as we should be doing best for the baby, which limits the procedures that are attempts that you're going to give a trainee. So I think all of it adds up for sure. And I don't know if there's a solution to it. I know there is definitely inequity in how many trainees we have here and how many we have around the world. So maybe expanding some amount of global health experience that everybody can get some programs I know have set this up. or they go to other NICUs in developing countries and try to help that way not just get experienced, but to give back to those communities as well. And everybody struggles with it, I think.
Daphna 25:15
Yeah, I think that's revolutionary. I think that would be really neat to establish some sort of pathway like that. I'm glad that you brought up the term, you know, equity, how can we be more equitable? Certainly, in terms of training, and I wonder, especially given the video technology, if some training programs will continue to do interviews virtually? And what are some other ways we can really work on equity in training programs?
Jayasree Nair 25:48
Yeah, no, absolutely. And this is the discussion every year, can we do away with virtual interviews? And I think the short answer that we all realize is that it's probably not going away. At best, we might get back to a hybrid interview, people do want to see where they're going. And, you know, it's always different when you meet someone in person, as opposed to just just over a webcam. But it doesn't big deal, not just for the for the candidate themselves. But as a program director, we used to have this huge budget set aside for wing and dining, all the candidates. And you know, I don't know that any of the hospital systems or the departments can afford it anymore. It's just not in the budget. So it's it's a it's a stretch for both, I think both programs as well as candidates are liking the first look at least to be virtual. That is a possible sort of hybrid version that people are talking about, which might include maybe a second visit in person, but you want to be careful with that, because only some people will be able to make the visit, if you make the visit, will you be ranked higher by the program. So one of the concerns brought up was it should be after the program submits the rank list that the candidate makes the visit. But how it's just it's just pretty tough. So basically, it's very tough. It's very tough to work that out. I do feel this time again, at the at PS recently, when the Oriente PD or the organization of neonatal perinatal program directors were meeting up. This was a question brought up again. And usually we look for guidance from the APPD or the, you know, cops, which is a pediatric subspecialties. And they usually give us some kind of read sort of recommendation, it's a guideline, it's not necessarily a rule, but everybody tended to go virtual last year, even for the people who were our own residents who were coming to interview, we still wanted to keep everybody virtual, and have the same rules.
Daphna 27:57
I have a question about what since we're talking about opportunities, and you know, things that you feel like, for example, educational opportunities that should be standard, right, every every program should offer but may not be able to give in the resources, especially in smaller programs or more rural programs. What do you think is something that is maybe lacking in in training that that maybe we can, maybe we can help standardize? I don't know.
Jayasree Nair 28:32
It? You know, you're you're absolutely right. And I while I don't necessarily want to say the pandemic had any silver linings, I feel like this was one of the things one of the good collaborations that came out of necessity was that again, a shout out to ntpd and to the leaders there who took it on and the basically shared resources, so programs that were holding large virtual teaching sessions opened it out to everybody else to the smaller and mid sized programs. Every all the all the program directors got together and organized a series of lectures that was going on, that's still going on actually twice a month, and has over 6200 fellows that attend every, every Wednesday, every other Wednesday of the month. So I do think we realize that there are many programs that are not able to offer the same educational resources even in terms of didactics Flipped Classroom series that's actually on method on the go portal and can be accessed by anyone in neonatology or in pediatrics. All these topics, you know touched upon neonatal physiology, several medical education topics even hot topics in Unit ology, all of these are on there. So I think the theoretical knowledge and the didactic, shared didactic education is out there. And it's it was publicized as a result of the pandemic. So most programs are now able to avail of those resources, which is way more than we had. I know as a program. Like if I talk about buffalo, we don't have cardiovascular surgery. So our fellows suffer from sort of having less of, you know, cardiovascular didactic topics. And so I encourage them always to seek out all of these shared lectures that would focus on this particular topic that I know we we are not able to offer really good didactics on. So I think for didactics, there's an option now, thanks to the pandemic, the hands on experience. I mean, as neonatologist, we know that no amount of simulation is going to replace actually being at the bedside and getting that experience. And, you know, how do we standardize that. So again, I do want them to get exposed to a seat CICU or a CTVs. So we have a relationship set up with another NICU in another city that's not too far away, to go and do an observer ship. It's not ideal, but there's ways to do it. And I think more institutions are open to sharing those options as a workaround, in order to be able to give the best experience we can to our cohort of fellows.
Ben 31:31
I wanted to ask you on this topic, then. I think that from the program director standpoint, the the goal really is to is to raise fellows into future attendings and making sure that they're ready, ready to face the world. And I think when people were being trained in the 70s and 80s, you basically logged in enough time and enough hours in the NICU and you saw and you gathered enough experience to tackle the world. And when you see how the knowledge around neonatology has grown and the number of pathologies that we're aware of these days. And it's very clear that there is no way for a single fellow over the course of three years to experience everything, or to even perform every procedure in the book. What is how has that shifted? The goals that are still the same for program director, which are we need to train good future attendings? So how do you adapt to this changing landscape? And how are these objectives different as the field is evolving so rapidly?
Jayasree Nair 32:37
You brought up a great point, you know, it used to be a time based fellowship, that's all you finished your three years you got out, you did everything you could during that time. A lot of it now is competency based in specific, you know, procedures training, clinical competency, scholarly achievement. So there's a lot more regulatory checkpoints, if you will, things we have to check off as a program director. But if I could tell all my fellows one thing when they graduate is that you just have to be willing to be eternal learners. You're just never going to never going to learn everything in those three years. And and you're right, I mean, the things that we have to not teach them you know, touching upon a few ethics, we do all practice ethics, right? And palliative care, we do all do it as neonatologist, but no one sits and teaches us that communication skills, oh my goodness, if we could, if we could all have communication as as an essential part in medical school, that would be fantastic. Because the number of times you call to defuse a situation or to calm down a family, some people do it instinctively, some don't leadership training, you're always leading teams as as part of a core team, all of that. And I don't think they get it. I don't think anything can replace experience at the bedside. If you have a fellow who actually did a pericardial tap live in a court situation, they're never going to forget it for the rest of their lives. But for everybody else, it's a story. You can show them videos, you can do simulation, but you're just never going to be able to give them the same kind of hands on experience that you know, someone that so and that that is limited by the work hours as well. Since you brought up the time based fellowship, I will bring up that we you know, the time that they are allowed to spend in the NICU is restricted whether or not they want it to be it is restricted, and not just by ACGME. But the states have different requirements. So New York state guidelines are actually tougher than ACGME more stringent and we are bound to we are going to follow it there's no doubt about it. It's just too much of fine that you have to pay for any violation that the GME is not going to allow it so that definitely restricts it I mean, it's in the end it depends on the fellow right what what is your path and I think that's where all the fellowship programs are going to look in the future. If you're going to be a private practice neonatologist, then am I doing you any good by sending you to a basic translational lab, I mean, you can get your publications. But if you know what you're going to do, there should be a track set for you. If you're going to be an educator, maybe we'll do better by getting you some educator training, so that you're able to start it up and have a bad set forward. Right. Most of the big programs have started to have these tracks, the clinical educator, the clinical, sort of, I think, the translational research scholar on D 32 grants. But I don't know if there's like a private practice set up can can we cover level two and level three as level four as neonatologist, but our fellows don't go to the level two, that's more like a private practice. But maybe some of them if they know that they have jobs set up, it would really be good if they could come out and see that kind of practice as well. So I think focusing on what the the individual fellow wants to do is probably important, we didn't think of it as much, but much like neonatology personalized medicine, I think personalization of sort of your fellowship training is going to be a way that you can try to give them what they need,
Ben 36:16
or at least to help them decide. Yeah, I remember when I rotated through my level twos, as a as a neonatology fellow was, it was an eye opening experience from the standpoint of, I can see myself doing this exactly on the back nine of my career, but it's not something I'm interested in pursuing right off right out of fellowship. And it helped me look for jobs, right? I mean, I knew that, alright, I'm not going to look for Level Two right now, maybe in the future, when I want to cut down, that will be an option. But for now, I'm more still more interested in the level three level four diploma.
Daphna 36:45
And conversely, I did not have that experience. And as you know, Ben, we started at a place where we did both level four and level two coverage. And it was the level two coverage that I found to be the most challenging because it was a totally different set of rules and expectations. And now we've chosen not to do
Ben 37:07
the credit the credit to my program director who has listened to the, to the same feedback from former fellows saying we're struggling in the level twos, yeah, and have him and then implemented mandatory level two rotations, which made this very easy like feeling comfortable discharging a patient, what to look out for all these things are things you don't learn in level four. So I wanted to move away a little bit from from being a program director and wanting to talk about about your story about you being being a mother being being a wife being a neonatologist, and how, how are you managing to juggle all these all these roles and and do it? So well?
Jayasree Nair 37:48
I don't think I'm unique in any way, when I say that some days, I feel like I'm hanging on by the safety of my hands. I just want to get through the next hour. It's all very, you know, what do I need to do? It's triaging what I need to do who needs to be rare. And my fellows are, they laugh at me, because I call them my other kids. So I'm taking one up kids, I have two kids at home. And of course, a dog to add to it. But it was my third third real kid, but you know, it happens. It just, it just moves on. It's almost like, you know, what's more important, right? And I think, if anything COVID And the pandemic over the last two years has has sort of reset everybody's life expectations or wishes, everybody what knows what's more important, and we are not afraid to say it anymore. I am not hesitant at all to say I have to go I have a pressing my son needs to be somewhere. Whereas three, four years ago, I wouldn't think of saying that the workplace. But now I've realized that it's okay. It's okay to adapt to accept all those roles, and to own it. And there's no way you're going to put them in silos because they are going to overlap.
Ben 39:06
So this is a very romantic description, because you're giving us the the, you're giving us the final product where you've you've arrived at this place, how chaotic was the journey? Because we've all because we've all gone through it. And and myself included, but COVID for many of us wrecked our lives for trying to have kids at home who were being homeschooled working in the ICU. So I'm just curious as to what was that experience like when you have so many responsibilities?
Jayasree Nair 39:38
Yes, I see panic in your eyes as well. And I feel like you just you went through it. You're absolutely right. No one prepared me. I mean, I wanted to be a teacher but not a teacher of elementary school kids, right. Bless them. I mean, they are those teachers are amazing. One elementary school kid and it knocked me over the edge. It was it was almost like I described it Somebody else like March of 2020 was, I was on service with my my colleague and friend. And we felt like we were going to war. We had no idea what was in the hospital. Nobody knew that code. Children's Hospitals were probably the safest place to be at which it took a good six months before we figured that out. But we were going in thinking we're going to bring disease back to our families at the same time. If you're a dual physician, especially or anyone else who's working out of the house and can't do remote, remote work, it's you have those kids at home, and what are you going to do? So when the schools closed, to keep the kids safe, I feel like in those six months, my daughter actually had seven babysitters, and two different weekends. So there was no lack of exposure, because we were struggling and we were just doing whatever we could to figure out a solution that's reasonably safe. I mean, safe as in I literally knew didn't know half the babysitter's that came to my house. I just talked to them over the phone. They were college students. And you know, you did what you have to, I think to say, everybody figured it out. Everybody figured out what worked for the family. But there was a lot of angst. I think that's the only time in my life that I ever subscribed to a meditation app. Right? Morning. Because you just felt like you need which one? Which one was it? It was that that Australian guy speaking I forgot.
Daphna 41:25
The calm app, the calm app. headspace,
Ben 41:29
I signed up for headspace. All you need.
Jayasree Nair 41:34
Headspace they were into that, yes, they were doing this three month free app for healthcare workers. I sent it to all my fellows. Got it. But I think routine really helped. Right? So there were things that we could check off and feel like we were in control that gave us control. So setting up a virtual teaching schedule for for the fellows having virtual check ins. You know, those things gave us some control over the workplace and really going back to the NICU or actually being in the NICU, I think was was like my grounding space that yes, this was the familiar space, I was okay here. And everything else just would fall into place. I mean, you You asked for help where you could. Another aspect and I have to throw this out is the one that caused me the most angst was that my mom has Alzheimer's and I missed two years of her life. I missed two years completely. And you know, they were alone. And I realized that no amount of money in the world could could provide food to them. Because there was no way that people were coming into work in the house. When our parents were aged, it was like thank goodness for relatives and friends that everybody's family stayed safe on the other side of the world. But it was so much of agony that everybody went through. Everybody has those stories to tell. So this is not unique by any means. But work, immediate home here, you know, loved ones in other parts of the world. It was all I wish I could press the delete button. I wish it would go.
Ben 43:05
I don't I don't know about that. Right? The question. I don't know, if we want to press Delete, because on the one hand, it was a very, to me at least it was very conflicting, because I felt privileged to be able to go back to work, because it did provide some balance, like the fact that I was able to maintain that normalcy of like, Hey, I get to go to work, and I still get to perform the same things. Okay, fine with with a shield and with with an adaptation, but that I felt I felt fortunate compared to my brother, for example, who's a lawyer who had to like state quarantine, he was in Paris, France, it's just like, you have to like lock the house and you're in the house. 24/7. That's very tough. But on the other hand, I'm wondering if you felt the same that it showed it highlighted our ability to adapt and overcome. And that's and that's and that's a hopeful that's that's the only hopeful message for me from this COVID pandemic is that we did manage to come up with a vaccine in record time, we did manage to keep the hospital in the US our hospitals did did fairly well, compared to other places in the world. And, and that's, I mean, that's the only hopeful thing that I'm taking away from this time because it was otherwise pretty, pretty tragic.
Daphna 44:11
Yeah. I wonder too, though, like you said, there's so many lessons about balance, and you know, that the face of program directors is changing, also. Right. And so this modeling that you are doing for, say your trainees, I think is incredibly valuable. I think one of the struggles that doctors have is that, that that balance may have been happening for their role models, but they didn't talk about it and they didn't share it. And so how did you ever learn how to balance or to find some coping mechanisms like a meditation app? Right? And so I wonder if that's something we can keep with us and what fellowship directors what you know, When CPD is doing to try to keep some of those in place as a structure.
Jayasree Nair 45:08
Yeah, no, absolutely. I think you're absolutely right. When I mean, if there's one good thing we take away from this is that we have the ability to adapt. Right? Nobody predicted this. I mean, yes, people did predict it. I think I read Robin Cook's contagion again, and thought, How did he come up with this so many years ago, this is exactly what happened. But people adapt. It's the resilience, it's almost like that's what attracted me to NICU is the resilience of the babies, you can do what you wanted them. And a two years, they still look amazing. And the same thing for all our I had fellows who went through three years of fellowship, never having gone to a conference, you know, missing out on some of the aspects of fellowship that are that are interesting and exciting, the networking, the none of that, and yet they cannot read. So I think it's the resilience that keeps you going. Your kids too, you know, a six year old was told to wear a mask. And you know what, they did it most of the time, in spite of everything, we we said that they wouldn't do that make whiny faces, nothing. They did it, when they were told to do it, they did it. So it absolutely is true. And that, that that's not going to go away. So what Daphna said is absolutely true. Now I see so many of you know, not just to ntpd there's a T cam, there's a mitcon There's a when women in neonatology I mean, all of these organizations that are able to virtually network now are taking this on and sharing stories and saying it's okay to be I don't even want to use the word word went out. I prefer moral distress. But, you know, at the same time, it's like we were all distressed, we all had things that we overcame. And I think it took a pandemic to tell us it's okay to talk about it, because people want to hear this. And people want to take lessons from what you know, you don't want to reinvent the wheel you this has been done before people have gone through it, maybe I'll find a way that will make me do better, or make make me feel better. So I don't think it's going away. I think there's webinars I mean, my calendar is full of things I want to listen to BTS was ridiculous, there was so many things I wanted to listen to, and I couldn't. But just because it was just this opportunity to actually go in person to some conference that hadn't happened for two and a half, three years. And it was and just meeting people, I think people everybody was so happy to see each other, that we spend more time networking than actually attending science. But, you know, it's, it's still so exciting to be able to hear those stories and realize, okay, people are human, right, all these I mean, I think one of the nicest things about your podcasts or hearing the first one with Dr. Carlo was he was so down to earth and this name that we hear about all the time in neonatology, but, you know, they're real people, and they're down to earth, and they, they are willing to share their
Ben 48:05
and they struggle with the same things that we are struggling with. And it's and that's I think, what this this this job that we're trying to do, of deconstructing the myth and, and the mistakes around around the ontology helps it in my opinion, other people just march forward. This is, I forgot what I was going to ask you. I'm sorry.
Daphna 48:26
Well, I know what I want to ask. We actually haven't touched about this at all on the podcast yet. But about being a to physician house. I mean, we have because Ben is in a two physician household, a dual physician household, but I mean, you I mean, when we talk about busy schedules, and you've alluded to the childcare issue, but how does that work? Balancing Your turn their turn and different career needs at different times?
Jayasree Nair 48:55
Yeah, I think you have to be lucky to find an amazing spouse. And you know, someone willing to take on, take share the responsibility with you. I think that's it to the best of our abilities. Like we literally would look at our schedule and say, can you find a swap? Or can I can can he do clinic virtually from home. So try to figure out who's, who could do it with the least amount of sort of, you know, trouble. And and it had to be done though I priorities were straight. I mean, I had the benefit of having a 15 year old at home 1415. So technically, he was allowed to be in the house with his sisters. We utilized him a lot. But you know, asking a 15 year old who's in school to also monitor a six year old Sisters is not not appropriate necessarily, and not something that we would do unless we had no other options. So yeah, telemedicine helped a little bit. It helped that my husband was not in a specialty that was intensive care. So some of the clinics could be converted to telemedicine, but in the end, it was really just depending on I had we have no immediate family around. But it was depending on this network of community people that I call my family, and everybody stepped up. And I think that's another thing that I learned during the pandemic is ask for help. And you will be surprised how many people will actually offer. I mean, our medical students set up a nanny, you know, Excel sheet and we're ready to offer nannying services because they were not going to in person med school. So they were there was helpful, and it was least expected. So I think I'm very thankful for the entire community that stepped up. That's so true.
Ben 50:35
I remember the time when I had to ask as a resident if like, I think one of the NICU nurses offered to watch my daughter for an evening and I was like, Man, I get used to having a NICU nurse.
Daphna 50:45
Yes. That's right, the high bar to set
Ben 50:50
a bar, it's a high bar. Go ahead. I
Daphna 50:55
know, we were running short. And we haven't even gotten to some of the other things that you're doing. We know we really wanted to talk to you about your role, your continued role in advocacy. I feel like a lot of times, neonatologist feel like I'm a subspecialist I come I do my work. But there are ways for us to get involved in our communities. So maybe you can speak to that.
Jayasree Nair 51:20
Absolutely. And you know, I was I did not grow up on advocacy as something that you had to do, right, we just did our work we went on. And that's another truth of being an immigrant here is that you don't want to get into trouble. You don't want to speak out and you know, get the limelight, the spotlight on you. And you pretty much put your head down and you keep working. So I don't think advocacy was ever in my residency program. Either. It is now it is in this residency program. 10 years later, there is a focus on advocacy and a group that is set up. And I have friends in the AAP who are doing wonderful, wonderful advocacy work and literally going door to door, especially during the pandemic, focusing on vaccines and things like that. So I do leave it to them. But another thing that happened around the same time was the gun violence, right? So I found myself right before the pandemic sort of pushed into this just from being from being a mom literally, hearing about my son having the drills where they hide under the table. Just brought me back to what what kind of schooling environment are we living in? I mean, I'm glad the school is doing the right thing. But at the same time, it's not something we were used to right growing up. And I found myself like writing to the, to the to the city newspaper, you know, opinion pieces on how do I protect my kid, you know, going for one of the marches against gun violence, and it's very unlikely, but it's just something that I think we have to, we have to we have to do and we have to be okay doing it is speaking up and the same thing. During COVID. At the school board, I think I ended up crying. I felt like I made a fool of myself. But I heard later from people that it was really it was needed. That's how that that was very powerful that we were able to speak up at all these venues. So I think I think we undermine our our own abilities to advocate. And that's something that I still don't have a neonatology. I think that's one of the drawbacks of our program as well. I do want to get them involved in advocacy. I see some of my residents doing it now, which is amazing.
Ben 53:38
I wanted to ask you one more question. And I remember now what I wanted to ask you. And I'm fascinated by the evolution of the role. female physicians play within medicine. If people like me are interested in medical history, I think the history of male physician is quite boring. I mean, we're male physicians haven't changed very much since the early days. But to read the stories of these female physicians throughout history, and the roles they've taken on a lot of time against resistance is fascinating, fascinating. And and we've talked to many female physicians, but what I'm interested in asking you about is there's this perception right that neonatology obstetrics is very much female friendly, because there's just more females in that field. And, and I don't think that there's ever I mean, the setting may be different than a female surgeon or like my wife, a female cardiologist, but I'm curious as to what are the challenges facing female neonatologist entering this field, even though there's a bit more female physicians compared to other specialties, especially in like, compared to the adult world?
Jayasree Nair 54:52
Yeah, no, I mean, you've brought up a great point and a point that again, is one of the hot topics of discussion and actually there's again the CD Use of articles that was recently published in the Journal of Perinatology. And some have some, you know, some more presentations along those when that were presented at PBS. And basically, that gender bias exists. I mean, I do. I am able to advocate for myself, but at the same time, I realize that I don't know the results of it. I do know that when you take a survey of neonatologist, you find out that this gender bias and the gender gap exists, not just in terms of the remuneration, or the financial payments that you're getting. But also in authorship and promotion. You know, all of this, right? It's data that's out there, it's hardcore data, it's been proven COVID, I think, made it much worse, because irrespective of like I said, I having a really wonderful spouse, or a very caring family around you, somehow, a lot of those responsibilities in fall to the mom, or fall to the female physicians, just naturally, I mean, it could be us ourselves, the guilt that we feel, it could be that the children gravitate, like the younger ones, you know, physically need, especially during the first year would need would, would possibly need a mom to be there, especially if you're breastfeeding, you know, those those, those needs do exist. And it's it would be, I mean, we have to accept it, that they do exist, but irrespective of whatever the causes, the point is that it really did take a toll much more on younger female physicians than it did on anyone else. And that's also published data that was recently came out by the same group, I think Horowitz and rhinitis ah, and they published it recently. The same thing happened with researchers as well. That was also something that was shown recently that, you know, funded researchers had the labs sort of the work was delayed, or the labs were shut, but again, the standard to affect more women. So I think it's real, it did happen, for whatever reasons, biological reasons, you know, community reasons, social reasons, it is there. And you might find a lot more I do, I don't know that I see it necessarily in neonatology. But I see it in other fields that a lot of women have taken part time roles are, that's what they're seeking more. And I think that's also another kind of personalization or customization that traditionally departments wouldn't offer part time faculty appointments. And maybe that's something that's very attractive, and would encourage people to give their all.
Ben 58:01
So I, my wife and I are talking about her going part time, by choice by choice. And I could not recommend people checking out a former guest of the podcast, Jimmy Turner, who basically will walk you through how to request part time from your from your chair, and not basically asking, but saying, I'm going part time, and he's walking you through the different scenarios as to what could happen. And he's just phenomenal. And it has empowered me and my wife to think about this as a viable option. Because we're like, yeah, we this is
Daphna 58:34
definitely I feel like to there's some sort of stigma with being part time, I'm part time. And by choice, and it allows me a lot more balance at home. And what I have found is it allows me to be much more present with my patients when I'm here and with the families. And I, I mean, I give everything when I'm here, and it has allowed me a lot of flexibility. And so I highly recommend what I hold, like you said, I hope our systems our systems will allow for more flexibility.
Ben 59:12
I think I think the Jimmy Turner mentioned that they will have no choice number one, and then my wife and I had this discussion about what is the goal, right? What is the optimal week look like? Just like Jimmy Turner explains, like, just envision what your perfect week would look like, and then just impose that on everybody else around you. And, and that's the way it should be. Because for my wife, when I asked her like, do you want to just stop working? It was clear, no, like, I love what I do. But if I could have like one or two more days a week to spend with my daughter, and with my family, this would make a tremendous difference. And it's like, Well, then let's just do it. So. So this is
Daphna 59:48
it doesn't just have to be the the mother right or the you know, could be for anybody, right?
Unknown Speaker 59:53
Yes, exactly.
Ben 59:55
I mean, we I feel I'm going to share something personal here but to me I feel so fortunate to be neonatologist because we have based on the schedule and under shiftwork, we have so many more opportunities to create balance within a full time position. When I see the demands on an on a on an adult cardiologist like my wife, it is preposterous. Like it is preposterous. Because I mean, like, yeah, some days I don't work, and it's a Monday and I don't work, like there's no such thing as as not working on a Monday, whether you are like, a cardiologist or an adult Endocrinol like no Monday, people you got you
Jayasree Nair 1:00:28
got to go to work. Full of people I know, full of people. Yeah.
Ben 1:00:33
I wanted to ask you one more question, because we're gonna have to close the show. And I know there's residents listening to the podcast, for residents interested in applying to fellowship, I meant to ask you that question, or you forgot. But their question that I've heard is, what should I be focusing on? How do I make myself a competitive applicant? I think there's a lot of misconceptions out there. Could you briefly just give us what you not like the the Absolute Truth, but like for you as a program director? Yeah. What makes an applicant pop out of the page? Or pop out of the list of applicants?
Jayasree Nair 1:01:08
Yeah, no, absolutely. And I, you know, I, again, these are purely my opinions, they are not the opinions of all the program directors in the US. But I look for the story, I want to hear the why I want to hear why you want to you want to, you want to follow this career or follow this path, and why you think that we might be a good choice for you. So look for something personal in the story, like I want to see motivation. Why are you doing this. So sometimes it's a very generic personal statement that's uploaded, right? You do. But sometimes there's a story there of why I'm doing this. And then it culminates with, when I actually meet you virtually or in person, I do want to hear your story, it's almost like that has to fall into place. And people joke when I talk about this, but I said, it's like an arranged marriage, you know, for a little bit virtually or in person, we are both on our best behavior. But at the same time, I need to know what you need to be happy. Because if I can't give you what you need to be happy, then this is not where you belong. So there's both sides to it. So it's very important for me to hear your side, if you want to do you know, echocardiograms, and you want to be an ECMO specialist? Well, I'm sorry, I'm not going to be able to provide you with the best training, I think there are other centers who could do better. So I know the limitations of my own center, and I want to be sure they know it too. Because managing expectations if it starts on, not necessarily untruth, but you know, on false beliefs is not appropriate. I don't want you to be unhappy. So it's funny that the way I found that there was a name for it, when I do two COVID, I took on like three courses and got three certifications in the last year and a half. And one of them was in academic leadership and one of so it's called Wellness centered leadership. And it's basically what you do. It's basically that you cultivate relationships with the team and the people. And you, you know, you sort of listened to them. And that's where you start from you pay attention to them, you spend time and you create that safe space, and you know what they'll take on all the responsibilities that come along. So that's what I tell my residents, like, I want you to be happy where you are and want to come here, be fully aware of what we we have, and then we build up from there, then we'll figure out where you need to go. And that will be our goal as well as yours. So I think that that story means a lot to me.
Ben 1:03:45
Right? So then I'd be remiss if I didn't finish the podcast by by recommending a book. You
Daphna 1:03:52
know, always does.
Ben 1:03:54
Why? Start with Why by Simon Sinek.
Jayasree Nair 1:03:57
I love it. I love it. Yes, it's an amazing book. If no one has read it. I mean, the story of how Apple started and you know, it's just amazing. I do completely agree with that recommendation. Yeah, start
Ben 1:04:09
with why by Simon Sinek. I will post it on the Twitter account. And then one more thing before we go. We talked about women in neonatology if you are on Twitter, I recommend you following at women and Neo. I'm not a woman. I'm following them. They're a good group.
Daphna 1:04:23
And information is good for everybody. Yes, correct.
Ben 1:04:27
That is correct. And so yeah, so Darren, anything else before we close the show? I mean, we're,
Daphna 1:04:34
yeah, we have tons of questions that we didn't even get to. I feel like we need to do two parts sessions with all over again. We really appreciate
Ben 1:04:40
your time. Thank you, Daphne, for making the time. Thank you, Josh, for coming on the show. I think this was very, very valuable. And your perspective is very refreshing. So so thank you for that.
Unknown Speaker 1:04:50
Thank you so much for having me. It was a pleasure.
Daphna 1:04:52
Yeah, your fellows are lucky to have you. Thanks for joining us.
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