Hello Friends 👋

This week, Daphna and I are very excited to bring you a fantastic conversation with Dr. Jae Kim, director of the division of neonatology at Cincinnati Children's Hospital, and his mentee Dr. Sai Mukthapuram. We really enjoyed our chat with them because we had the opportunity to dissect how we, as neonatologists, welcome change in our careers and how we perceive new opportunities. It was valuable to have someone with Dr. Kim's experience share his thoughts on this idea and walk us through so many examples he has encountered such as the introduction of POCUS in the NICU or the opportunity to lead a large and high-quality team like the one at Cincinnati Children's. We hope you enjoy this episode and thank you for your support and loyalty.

-Ben

Bio (Dr. Jae Kim MD): I am a pediatric neonatologist who specializes in the care of newborns who are born prematurely, as well as infants who present problems at birth and within the first few months after birth. Our team provides the highest level of care in the nation for the sickest infants and those with the most complex conditions.

In my practice, I believe that a holistic approach to care is necessary now more than ever. This is especially true in the neonatal intensive care unit (NICU), where technology can sometimes overwhelm parents. As physicians, we must be great listeners and observers in order to deliver the best care to our families. We watch for the subtle changes in our babies as well as the dynamic changes in their families that can occur on a day-to-day basis.

I am proud to lead a team of healthcare professionals who work together in the 14 different NICUs and newborn sites across the Cincinnati area to provide exceptional newborn care. Our team engages in fetal care before birth alongside our obstetrical colleagues and takes care of infants during the time of birth and after birth when problems arise. We couple this care with important bridges to scientific discovery in the areas of laboratory research, clinical research, quality improvement and follow-up care for the best long-term health outcomes.

I assisted in the formation of two donor banks for human breastmilk – one in Toronto, Canada, the city where I grew up, and the other in San Diego, California, where I practiced for over a decade. I consider these breastmilk banks to be among my most significant accomplishments.

In my research, I have had a long-standing interest in newborn nutrition, with a particular focus on a mother’s breastmilk. The lifesaving properties of breastmilk are still in an exciting period of discovery. We continue to uncover new benefits of breastmilk, including its ability to pass on immune protection to babies and to alter the microbes in their gut to stimulate the best environment for their gut health.

This is especially important for infants with the worst type of gut inflammation, a condition called necrotizing enterocolitis (NEC). My interest in these infants is deep-rooted, and I work with other clinical research scientists, laboratory scientists and breastmilk specialists to better understand this condition. Our aspirational goal is to have a world without NEC.

I am also dedicated to strengthening our care of infants by integrating more advances in technology, such as improvements in the use of monitored data and electronic health data, as well as softening our care with the integration of family-centered care practices. The future of newborn care is going to be very data- and technology-rich, and our challenge is to preserve the human connection with this modern care model.

My wife and I are proud parents of two grown adults. We love to travel to different countries around the world and experience their cultures, music and food. I am a fan of swimming, hiking, cycling and playing (preferably scoreless) golf. In Cincinnati, I especially enjoy the many forested walking areas, which offer a calming balance to work.

Bio (Dr. Sai Mukthapuram): Doing the right things at the right time can give sick babies an entirely new life. Since my medical school training in South India, I have wanted to become a neonatologist to help sick newborns. I believe training and mentoring fellows, residents and medical students will lay a strong foundation to help advance the field of neonatology as trainees are the future of medicine.

My areas of research include medical education, point-of-care ultrasound and quality improvement. My goals are to introduce point-of-care ultrasound curriculum in neonatology and other innovative evidence-based strategies for the advancement of medical education at Cincinnati Children’s.

I received the Reginald Tsang Outstanding Fellow Award (2018), the Outstanding Fellow Teaching Award (2018 & 2019) and the Outstanding Faculty Teaching Award (2020), all from Cincinnati Children’s. I am the communications chair and secretary for the American Academy of Pediatrics Section of Trainees and Early Career Neonatologists (TECaN). I’m also board-certified by the American Board of Pediatrics (2016)

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

Ben 0:54

Welcome. Hello, everybody. Welcome back to the incubator podcast. It is another week of interviews. We are very excited today. We have we have two guests actually. Is there I mean, we're gonna give, we're going to introduce Dr. Kim and Dr. Mukhtar Param. In just a second, is there anything that we needed to talk about?

Daphna 1:22

Well, yeah, maybe to remind people if they wanted to do their end to grant applications.

Ben 1:27

Oh, that's right. Yeah, the new neural network grants are going to close in about two or three weeks, at the end of the month. We've already received some applications. Thank you, for everybody who has already applied? And yeah, it's, it's a we

Daphna 1:39

want to give away money. I mean,

Ben 1:43

I mean, we have we have educational funds to give away, let's not

Daphna 1:49

listen at, you know, I'm not, you know, you and I both struggled to fund our, you know, initial research, and everybody just needs a little bit, just a little bit to get started.

Ben 2:02

So I'll keep saying my lack of funding was exemplified by my need to hack SPSS in order to be able to run my stats from my studies. So I know the struggle is real, especially as a fellow there was this one time as a fellow where we suddenly saw like $2,000 missing from our bank account and was like the loans or educational loans that had somehow kicked in like the repayment had changed or something, it was like, Oh, my God, like it was it was devastating time. So definitely getting funding for your research funding, your research should not come at your at your personal expense, if you can avoid it. So take advantage of that. And we're very happy to boost the work being done by young courier neonatologist and trainees. So definitely apply and continue sending us recommendations for guests. The podcast is doing very, very well. And it's it's a blessing and a curse. Because on the one hand, there's so many great names. But for example, the lineup is pretty much closed for the rest of the year, obviously. And we're looking at the lineup of guests for next year. And there's not I mean, there's 26 weeks to fill and they fill up quick. So if you have any ideas, or anybody you want to see on the show, please let us know. And many times, actually the recommendations we get are already recorded and ready to roll out. So that's always good feedback. But without further ado, let's talk about the guests that we have on today. We are actually very much honored to have on Dr. J. Kim. Dr. J. Kim is the division Chair of neonatology at Cincinnati Children's Hospital and he got his medical training at the University of Toronto in Canada and did his residency at the Hospital for Sick Children in Toronto and got his PhD there as well. He completed his fellowship in neonatology and pediatric gastroenterologist Catherine gastroenterology. I'm sorry hepatology and nutrition in 2001. He is very much involved in neonatal gastroenterology research and also in point of care, ultrasound and new technologies. He is joined today by one of his I guess we can call him his mentee Dr. Tsai Mukhtar param, who got his medical degree from the Venkateswara Medical College in India and who did his residency at Beaumont Health in Royal Oak Michigan, and completed his neonatal perinatal fellowship at Cincinnati Children's Hospital Medical Center in Ohio. I'm stumbling a bit out of the gate here today. I apologize. It's been a long week, but we're so excited to have them on. And this interview is phenomenal. I am a big fan of Dr. Kim. And yeah, we hope you enjoy this interview. Dr. gkm Dr. Se mocked up poram Thank you so much for being on the show with us today.

Unknown Speaker 4:56

Great to be here.

Ben 4:58

Thank you guys. So, Dr. Kim, I wanted to start asking you a little bit about you have an amazing career in the field of neonatology, your career has taken you many different places. I am wondering if you could give a little bit of an introduction as to how you found your way into neonatology. And what has your path look like over the years going from Canada to the West Coast of the US to Cincinnati, please,

Jae Kim 5:30

yeah, I would have to say my journey is a little circuitous compared to most so I did train in Canada, I grew up in Toronto, and I did my a lot of training up there first in pediatrics, after medicine, and at that time, I had a very strong interest in pediatric Gi. So in fact, I did not start off as a neonatologist actually started off as a pediatric gastroenterologist and got very interested in the science around cell biology and started a PhD program in my resident, my fellowship years in GI, but actually was on the journey to be a pediatric Gi. And as I was finishing, I had a opportunity to stay at sick children's. And in order to do that, I the requests that came from the chair was would I be willing to train Additionally, in neonatology to stay, stay it because at that time, they had someone who a senior person, Max Perlman, who was retiring, and they needed a replacement. So that was the offer that was given to me. And at that time, I was young. And I felt like yeah, what's what's a few more years, and I was able to do some postdoc training as well on top of that. So I did that, and became a neonatologist. And

Daphna 7:00

what a lesson and just taking the opportunities that, you know, you're you're confronted with that it's so interesting.

Jae Kim 7:09

Yeah, and I think part of it is just i and i, this is what I tell prospective fellows or even faculty is that if you follow your curiosity, if you really follow what really interests you, then it's going to be a good journey. And I certainly experienced that and having always had an interest in nutrition, and the luminal, although livers great too, but luminal Gi, it just got me to the area where neonates and bowel issues are is was so, so important. And as we after we solved a lot of the lung issues, although we haven't completely solved all the lung issues. In neonates, a lot of the challenges was growing babies and the and feeding babies and nutrition became a really big thing. So that the combination of gi n Nutrish and neonatology made sense for me and my interest.

Ben 8:05

I love that you're saying this, because when you look at your publications at your path, you clearly see this interest in GI and nutrition. And you also see a lot of diversification of your interest, right? I mean, we're gonna talk about point of care ultrasound. And I really appreciate you saying that young career neonatologist should really pursue their interest. Because there's this feeling this almost this guilt that if you've picked your lane, it's like, oh, I cannot really get interested in point of gouges. And I'm supposed to be I don't know, like the BPD person. But can you tell us a little bit about freeing ourselves from this guilt of like, No, you it's perfectly fine to explore a multitude of avenues and and maybe piece things together?

Jae Kim 8:50

Yeah, I think the the, it's challenging, right? Because in order to be in an academic pathway, you really do have to focus so but at the same time, if you stifle all your curiosity, and you only focus in one area, it's it can be very limiting. And, and, and to me, I think the the most enjoyable thing about medicine and particularly in neonatology is that we don't focus on one organ, we focus on all parts of the body, and all function and physiology and mechanism is such a foundation for neonatology. So why can't we be curious about all those areas, particularly as a by the bedside, having that clinical curiosity? And then using some of those rules and sort of inspiration when you're thinking about what's causing this problem in a particular child and then trying to solve it has a lot of cross applications. So I always encourage people that after you've gone to the burden of medical school and residency, is that you got to rekindle that fire that got you into medicine in the first place, like what was interesting about biology, human biology, and interesting about these these conditions and diseases that happened to our patients. And to me, that's when your enjoyment of being a doctor and being a neonatologist really kick in. And I love seeing that with junior faculty, when they start to focus in an area and they they allow their curiosity to really grow in in a particular field. And then, and then it's positive. And you know, when we get our faculty together, and we talk about different things, I want people to be able to share their curiosity in other areas, you know, you have one major lane, which is your primary highway, but you are trained to be a really creative and broad thinking person. So having an opinion and having curiosity in other areas, I think is really, really important.

Ben 10:59

Without getting into politics, I'm a big fan of Andrew Yang, who recently spoke at the commencement to give a commencement address at the Columbia Law School. And he said something similar, where he said, these advanced degrees, give us the the Get Out of Jail Free card to explore things that other people may say, What are you doing? And I think this is great. This is exactly right. You went through medical school, you went through advanced training, you have the right to explore, and maybe you'll be wrong, maybe you won't find something that will materialize into a long term, research project or anything, but at least you're allowed to go roam free. I love that. I love that concept.

Daphna 11:41

Yeah, I actually have a follow up question to that. I don't recommend people do what I did. And fellowship was take on so many projects, that you had so many mentors, that it could be a little overwhelming, but you obviously have a number of leadership roles. And so I wonder for trainees, you know, any guidance that you have for people who have multiple interests, still, they're still trying to figure out there lanes, so to speak, and managing the expectations then have multiple mentors.

Jae Kim 12:15

Yeah, so that's a really, it's a universal problem. And, you know, I faced that as well trying to figure out what what was most interesting as opposed to being tugged from different directions. So I think the key thing is, is really identifying a primary area that you really can sink your teeth into. And mentorship, as you mentioned, I think that is absolutely important. You people are created or broken down by the mentors that they choose. So I really think it's important to take the time to identify a good mentor that really can understand what your needs are. And if that shared sort of decision about what your career path is going to look like, and what project is going to be fruitful for you. The mistakes I've seen in I've made many of these is, is being over ambitious for at a fellowship level, and choosing something that's way too big for that period of time to be able to accomplish. And so finding something that and then the flip side of that is is choosing a project that's too small, too easy, isn't stimulating enough, but yeah, it will generate a paper, but it really doesn't have any impact. So it's finding that sweet spot where it really is something that everyone is curious about in has high impact. But you think realistically it can be finished or mostly completed, completed in the fellowship year. So I think that's that's the challenge. And I think the other thing I see is everyone who's bright is going to have a lot of things that are interesting to them. So trying to be facing that challenge of being able to whittle away a list of five and bringing it down to you know, two or three, something more manageable, has to be done is is hard, but it has to be done in order for things to really grow. Well.

Daphna 14:15

See, I never I never whittled down my list.

Ben 14:21

So I wanted to get started and talk a little bit about point of care ultrasound because obviously it's such a hot topic, everybody is looking into it. Dr. Kim J, you've been one of the early neonatologist to at least recognize that this was this was an avenue that needed to be explored. I am wondering if you can walk us through what's your thought process in the early 2000. When you start realizing that like alright point of care ultrasound is something that we do not use. Maybe you saw that in other specialties. I mean, you mentioned your training and gi so I'm assuming you saw you were very much conscious of its use and other special OTS how does how does one go from the thoughts of maybe this is something that should be used in the NICU to the conviction that alright, we need to do something about this.

Jae Kim 15:12

So, so I think this is sort of following my nose into sort of mid 2000s I actually was managing a lot of babies with neck. And we had a, I had a conversation with one of the radiologists who said, you know, and he was primarily working on as an ultrasonographer. And he said to me, you know, I can see, just wanted to let you know, I can see NUMA ptosis really well by ultrasound. And I said, What do you mean, and we went through a conversation about like, oh, we because we never ordered ultrasounds for neck specifically for about we may look for, you know, IDs or something else, but not look at bow, they always in fact, they would look away from valid because the bow had gas in it. So it was typically not area to look at. So when he mentioned that it's it spawned an interest within the radiology group there, that we started a number of papers to look at what is the value of ultrasound in evaluating neonates with threatened bowel. And that opened my eyes that, hey, here's this really non invasive tool, which we used in the NICU all the time, we ordered it for head and chest, and F, you know, all parts of the body. In fact, in one of our units in Toronto, we actually had a very old ultrasound machine that we could pull out it late at night, if we wanted to look at a head that had head bleed, that was emerging in the middle of the night, and it was available to us. So there was a little bit of access. So it became clear to me that this is a really unique tool. And when we started actually looking at a number of babies in Toronto, the views that we got looking at bowel, you know, basically right up front, seeing the bowel moving or not moving and thickened. Or, and in the case of really bad surgical neck seeing it non-viable, not perfused was really eye opening. So it was clear to me that ultrasound in general opened a window to the body of our neonates, which really are very interrogate people, more so than even other patients. And yet, we didn't we have not, we didn't touch it at that time. So it was it was the start for me that this is an area that we ought to explore. And it was a side project, to be honest, because I was focused more on, you know, human milk, nutrition and other other things. So when I came to San Diego, the first request that I get I had was that it is to have access to good ultrasound equipment in order to start understanding what value other potential values there'd be for using ultrasound, or neonates. And so it's a bit of follow my nose for things I thought would be reasonable and develop couple of projects that fellows jumped on to. And we looked at sort of value of looking particularly around catheters, because I thought, here's something that's very easy to see. And I think it'd be very practical for us to be able to detect umbilical catheters for proper ultrasound guided insertion, tip location, and the same for for pics as well. So that was sort of the the way I got into it, but it became greater of greater value as time went went on,

Ben 18:55

and save us a lot of time waiting for X ray. Yeah.

Daphna 18:59

Well, that's what I wanted to touch on before we get into the nitty gritty and we have a lot of ultrasound related questions. But for both of you, what do you say to clinicians who say, I don't think we need I don't think we need ultrasound in the NICU or I'm not interested in learning ultrasound in the NICU? You know, I'm not sure that's our listeners, but it could be so what what do you say to people who are thinking maybe this isn't a research priority?

Jae Kim 19:30

Yeah, that's a good I'll say something and maybe thought you might want to comment as well. I think there's this great image graph. I don't know if you've seen the diffusion of innovation, and it it sort of has this sort of a typical histogram type picture. And, and in any group, you're going to have people who are early adopters, and on the other end, you're going to have people who are laggards and Then the majority sits somewhere in the middle. And I think ultrasound has been exactly that in neonatology and also other specialties. One observation I've seen in critical care medicine in pick us is this belief by many of the attendings that, oh, they know how to put in central catheters by landmark technique and just do it the old fashioned way. They've been doing it forever. They've been doing it forever, they're not willing to change. And yet, what happened in their specialty is that their fellows all started learning universally to use ultrasound guided insertion. It was an inverted model where you had laggards in the attendings and the new people coming up. We're all I wouldn't say that early adopters. But you know, a lot of them were because they're being basically told that this is the way you're going to train. They all learn. So it's a fascinating inversion of learning. And I see that potentially being one of the things that we'll have to face in neonatology that there will be laggards, that's it I'm, I don't have time to learn. And I don't think it's of great value. Although most people, including senior people who've been around when they see the value of it, they say this is really great. But how am I going to find time to learn this? Who's going to teach me how, how am I going to get credential to do so?

Ben 21:30

Say you weren't you were gonna say something.

Speaker 4 21:32

I was just gonna add on to that saying almost similar to the laggard and early adopters analogy, I was gonna say, change is almost like a marathon, right? Some people want to get to the end line faster than the others, and some are just taking their own time to get there. I feel like once everyone starts experiencing the fruits of point of care, ultrasound in their own unit, in their own practice, like waiting in the sterile gowns for 3035 minutes in the middle of the night, when an x ray machine knows,

Daphna 22:05

Reason enough.

Speaker 4 22:08

Yeah, especially during COVID time, that could be an hour. And yeah, if one experiences that versus just pulling out a probe and putting it on and making sure the lines in a good spot, or BT tubes in a good spot are simple, practical applications like being successful with your lumbar puncture. I think I think more and more people adapt and get into this. And as you rightly said, it is a hot topic, and there is a lot more interest, even in the past few years, everywhere. So excited for all that stuff.

Ben 22:45

Yeah, and I'm not sure if you agree with this. But I also think it has to do with the evolution of our field. I think what you were describing Jay about older attending, saying, Well, I can do it with landmarks. Well, they also had the benefit that during their their I guess the peak of their career. They were doing many more procedures than we do today. I think today we're really focusing on how can we reduce the number of intubation? How can we reduce the time for central lines. And so the young generation doesn't have the benefit of volume. And so they I think, have to trade off the volume for precision. And this is maybe where this interesting shift that we're all noticing is probably stemming from?

Jae Kim 23:24

Yeah, yeah, you're absolutely right. Yeah. The other thing I think that's also weighing in as we go forward, is how much more patient families are involved. So in the past, if you did landmark techniques, or you had whatever practice, you spent time energy and you failed, a lot more than with with the use of ultrasound, so I don't think there's going to be as much tolerance for for that sort of imprecision. And I think as we learn that and prove and validate that option, better, there's going to be a demand that, that that is if that's the state of the art, then that's what needs to be practiced in my child or in in my baby.

Ben 24:12

I wanted to go back. Oh, go ahead. Sorry.

Speaker 4 24:15

I just had a quick point. Another point that I like to sell focus on is one of the applications that should be tackled last but let's say you have a set of trends in the middle of delivery in a delivery setting, which one of the trends has a cardiac lesion. And in utero, those trends could be A and B, and A has a cardiac lesion but when they come out, who knows which ones weren't? Yeah, unless the rates are completely discordant. So if you have someone skilled to put a probe on and the key is to distinguish between a normal and abnormal heart that's that's another point to sell it sell. So I was

Ben 24:57

in that position that a level two as a fellow was covering level two and two twins came out. One of them was supposedly one of them actually had hypoplastic left heart and, and at the time when I got to the delivery room, they couldn't tell me which one was which. And so it began. I feel the stress. But you know, let's I wanted to get into the nitty gritty of of developing ultrasound. And I want to start with what you describe Jay, that sparked your interest, which was interesting, because it was a collaboration, right? It was an interaction with radiology. And you've mentioned in writing in the past that the success of point of care ultrasound programs in the NICU will be hinging on our ability to effectively collaborate with other departments such as cardiology, radiology, maybe even pediatric ICU and pediatric er who have already passed the point of establishing point of care ultrasound in their specialties. Can you tell us exactly what that looks like? Because I think a lot of people sometimes want to get this off the ground, and then the rumblings start around the hospital from other departments saying that they shouldn't be doing this, and so on and so forth. So how, how do we approach this issue? Effectively?

Jae Kim 26:08

Yeah, and I'll I want to make a maybe a preface comment that, that the situation changes over time. So at the beginning, what makes sense, rationally, let's all play in the in the same sandbox. And there's enough room for everyone to have opportunity to scan and and get renumerated appropriately. Does, it's like any quality improvement, activity change is difficult. We're all creatures of habit. And so when you impose something different, like we're, as a neonatologist, and a provider, we're going to pick up an ultrasound. And it just sends off ripples through many directions. And so I think, at the beginning, there was a lot of trepidation. What's nice is that I think we're at a stage where there's enough activity and interest out there that things are softening. It's certainly not perfect. But I think things are softening. So the same construct of saying, hey, let's all play in the same playground and actually start being able to partition off what that workflow looks like. So if we scan, there's still opportunity for radiologists to evaluate more formally, or for cardiologists to evaluate more formally. So I think that getting better, but certainly at the start, there was huge limitations. And I would say, the reason why we were successful in San Diego was because we were at a at a delivery Hospital, a little bit more removed from the Children's Hospital, to cardiology, could not come over so readily. So the ability for us to have our own technician and access to equipment allowed us to have little more freedom to be able to for especially for me to be able to just scan whoever he wanted scan and develop projects around that. And that was the opportunity now now I think there's just a little bit more openness by other specialties to see the potential now that we're seeing critical care. And an IDI, having already created some somewhat more of a runway. I think that that's improving. So I think maybe you could talk about how we navigated the collaboration within our hospital.

Speaker 4 28:45

Absolutely. And yeah, like our biggest learning when we were building our program was that there was our intensive care colleagues or emergency medicine colleagues who've gone through the same painful processes of how to get med staff to credential you for point of care ultrasound, how to document your workflow in your electronic medical records. And just even within the first couple of meetings. Those collaborations like have laid a strong foundation on how this program could be built upon. And those connections, I would say were really instrumental in getting some of the work behind the scenes done like billing codes are like your EMR workflow, and, yeah, and storage of images on all those problems that are really vital, but at the same time could be tackled together as a larger group, not by yourself, which makes it much easier so

Daphna 29:50

so what I hear you saying is collaboration is key, and to use those resources. So say some of our listeners are at a hospital. That's not readily using point of care ultrasound, what do you think is like the first best step, either as an individual, and you know, and as a as a team or as a hospital system?

Speaker 4 30:17

I think I think identifying, identifying the key applications, what they want to do the use that ultrasound for, and where they want to use the point of care ultrasound would be the first big question they need to ask themselves, right? Like, whether they're going to only use it for diagnostic applications, whether they're going to use it for diagnostic and clinical procedural applications? And what are those procedures? Are they simple things like just bladder ultrasound, and ultrasound, and along the ultrasound? Or are they like looking to do cardiac point of care, ultrasound? So all these are important first questions, at least the first step, and they will guide the next for next steps in the direction of establishing a program or establishing a practice guideline for themselves. So I think asking that question of where they plan on using the ultrasound, I think is one of the first important steps that came.

Jae Kim 31:19

Yeah, I totally agree with you sigh. And one of the perspectives I think we need to get to your listeners is that this distinction and separation between cardiac and noncardiac. So if you look historically, how we gravitate as neonatologist to bedside or point of care ultrasound, it was largely because of an interest in the ductus and trying to figure out what we should do with that ductus in a remote place if you didn't have access, per se to cardiologists immediately. So internationally, that was a big driver is trying to find out what is the heart looking like and particularly what the ductus is looking like. And so people learned cardiac point of care ultrasound a lot further and faster because of the need. And if you look at all the different practical applications, the cardiac is obviously interesting, but it's also the hardest. And so as a specialty, I think we shot ourselves in the foot, to some extent, because we took the hardest thing, put it on the pedestal and said, This is what we're going to go for when we talk about point of care, ultrasound. And I think it's limiting because any group right now that says I'm going to be full fledged trained, and have all members trained in point of care, ultrasound for echocardiography, it's a huge lift. And, and there's a lot more published in terms of what the requirements are for that, and it's a lot of scans and a lot of mentoring. So what our approach, Sinai had really thought carefully at the start to say, we're going to look at noncardiac because it's the low hanging fruit, it's the thing that if we had redesigned this whole area before from the start, why not start with the easiest, like bladder, or lung, or even head since we see head ultrasounds all the time, we know how to read them, start with something simpler, and enable people to get comfortable with the machines comfortable with the practice and get other people comfortable with DNA colleges holding the probe and, and scanning and making clinical decisions based on that. So I think that's a real important decisional like looking at that, when you're trying to start a program is it's it's sexy to go for the heart. But we really have to think about what's pragmatic, and what's the best way to get adoption. And so our approach has been Yes, we will train to look at the heart but let's start getting everyone to see what the bladder looks like let's start like really, really low low level and then get people graded upwards in terms of skill set.

Ben 34:18

I think this is where there may be a discrepancy right? If you're trying to sell your department or your institution on for example, buying the ultrasound machine, you may want to say hey, we're going to do all these things you know, like the heart the bladder this that and then you have you're committing maybe subconsciously to like all these things when in truth you should do a more stepwise approach and so I I want to actually get you a get a list from you but like on a scale of like easiest to a bit harder. You say bladder is the easiest, what would be like the the first three things you should explore in order, because I'm wondering that there are things that like you said, are very easy like the bladder, but there are things that are so needed, like psi was mentioning earlier, like the, like the position of the catheters. So if you had to give us like a bit of a a list of easiest to a bit harder, where would you rank those, if you don't mind?

Jae Kim 35:13

Yeah, I think so I can also interject. But I think bladder is clearly it's a it's not a moving organ, it's right there above the pubic symphysis. So it's, it's pretty obvious to identify. And in from practice it most people can identify a bladder, the harder part is looking for an empty bladder. But even then, once you get used to where the location is, it does not take that many stands for you to become relatively confident of identifying that. And then it be arguable after that, what's the next easiest, I think, I think long is actually not that hard. Because it's not as landmarks specific, you can move around and you can detect things, there's a few techniques that you have to do with the M mode, for instance, on on lung that you just have to visually learn what that looks like. I think catheters are some of the catheters, identification is actually really quite straightforward. But there's a little learning curve to first figure out how to find an IBC, or an SPC, which is a lot harder to find. And is definitely a little bit more of a scale up. But not all catheters are or identification is that difficult, I'd say upper picks, for instance, are, are really challenging for most people. Whereas lower picks are almost dead easy. Once you figure out how to see an IVC you can find a catheter in there. Because the catheters are so echogenic they're, they're obvious to see in the vessel.

Speaker 4 36:49

I was gonna add a head ultrasound focus, like right there at number two with the lung too, because as neonatologist, we are trained to look at a bunch of head images, grade one, grade two, grade three, grade four, even from the fellowship days, or even residency days, we are trained to look at some of those images and say what grade it is right? So and the font now being so accessible, right there, and doesn't like take a lot of skill to get good images with head head also falls right there within that top three list. And, and for for places where you're practicing, read, you don't have a sonographer available overnight, you have a micro preemie who is crashing on you don't have a reason, it's always easier to put a probe on to identify a large hemorrhage. So head head also goes right up on the list there.

Jae Kim 37:46

Yeah, distinguish those techniques that are difficult to do like the heart because you really have to have good dexterity and hand eye coordination to be able to imagine and visualize the heart in three dimensions. As you're scanning with a 2d Pro, versus techniques like head like sai saying where we're really used to seeing the images and the fontanelles right there. And it's not that technically difficult just to figure out orthogonal positioning, and then capture images so so each technique is slightly different terms that ease but separating out like what's easy to read in terms of the images versus what's really easy to do technically, with with the actual machine.

Ben 38:32

I have one more follow up question mostly for for sigh I guess for for people who are in a random institution, and I'm saying random because I mean, an institution that does not have an established training point of care ultrasound program, because obviously if that's at your disposal then great for you. But like for the audience, who is saying I've never held a probe, where should I start? Do you have any good tips? Is it like some a YouTube channel? Is it a book? Is it a website? Anything that has helped you, as you've trained into point of care ultrasound

Speaker 4 39:07

over the years? That's a That's a fantastic question. Like there have been several law design well structured courses that happen once or twice a year within the neonatology community. One such a one is a chop they have it twice a year. And the cool topics and neonatology on the West Coast has once a year in March in San Diego, UCLA has another course that also happens annually. There are several well established courses like even if the the learner who wants to set up their own program goes there for a couple of times initially, and then starts practicing, like hands on sessions at those courses as well as bring those skills back using ultrasound machine and try to get some of the basic images. So again, starting with small applications like trying to image bladder, you will practice those macro and micro movements with the ultrasound probe when you come back and then slowly build on those applications. And the one thing Dr. Kim and I always talk about is having having a hands on session or virtual office hours by pokes experts across the neonatal community is going to aid it, some of these individual learners at smaller programs to have, hey, I have a quarterly session with focus experts across the country. And I can get ask all my questions that have arised in this quarter on where I'm doing things wrong or says where what's my next best step? So I think from a training standpoint, some of these courses teach you the skills practice has to be more, especially if it's a smaller place like mostly themselves. If there is willing radiologists willing sonographers who can supervise or guide them within certain skills. That is excellent. That could be the next ating step. And having constant collaboration with national experts like to reaching out to them with questions on what the next best steps would be is another thing. There's lots of great resources on YouTube. There's lots of great resources like as early career neonatologist, Tieken, has a pocus, chat group where there is documents including credentialing shared, right how to get yourself credential at your office, like there's lots of collaboration ongoing in those chat groups where people are willing to share what kind of procedural competency they've established with their program, what kind of educational materials they've been distributing at their program. And we were actually, Tikkun was able to create a repository of those and we are, we freely share those with the neonatal community on that on that chat group. So there are several great resources, but I think starting out with one of those conferences, and then and then trying to find radiologist or sonographer at their own pace, while they practice to aid the skill, skill development would be the most helpful. That can also

Jae Kim 42:41

be on TPT is the other one, I suggest you you're involved in that. So at the fellowship level, there's some activity trying to generate a curriculum around point of care ultrasound, which I think it's also important. The other course that that's large has been running as the Society for critical care medicine. So it's from the adult side, but they have a pediatric and now neonatal ultrasound program, and they've run been running that twice a year, and now just once a year. And I think that's, that's another really good multi day course that people can train at. And the the side mentioned, it, it's not UCLA, but it's like a USC. But there's so there's opportunity to train to for an individual. But I agree with science practice, like you get you get real knowledge when you learn some basics, you know, got some didactic material and some hands on coursework. And then you actually have to scan like, you just have to scan a lot of babies. And that's how you get comfortable with it. The good thing is that technology is chasing us and improving in terms of image quality, the frequencies that were getting, and the use the portability of the of the devices and the cost of the devices have come down significantly. So that is not the barrier. The barrier is what Simon mentioned, which is education. We have a lot of neonatologist in this country. And if we want the specialty to change, and we have a lot of people that has to learn that not a small modicum of education. It's a fair amount of both didactic and hands on training in order for us all to feel confident and competent in doing point of care ultrasound, so that because that's the barrier.

Ben 44:33

In time the fellows will get training and fellowship, but it's about training this whole group of neonatologist who are out in the world that need that need. Yeah, I agree.

Speaker 4 44:42

And another thing I'll just add to that is, I think I think this is an area where neonatologist can be creative, right? Like, find a program that's close to them that has an established focus program and do some time like ask them reach out to them saying, Hey, would you mind if I came and practiced or learned skills like or shadow you even while you're doing some of your focus and almost like an elective at a neonatologist level, and I think the focus community in neonatology is so great that everyone's willing to help out each other. Everyone wants everyone else to learn and succeed in that area. So I, that would be an innovative way of like setting up electives, or setting up shadowing to enhance enhance skills further than the courses itself. So

Ben 45:34

yeah, I

Daphna 45:35

was gonna say that, that I've found that our Neos for doing POCUS are just so excited that somebody else wants to learn POCUS that they're, they're happy to bring you along for a scan or whatever. You guys have alluded it, alluded to it. And I think you're right that probably the training programs, and we'll we'll be the, you know, major adopters initially. And I wonder if you have any tips for, you know, the, the team has decided, yeah, we think this is important. I took a course I kind of know the basics, but I really like you said gotta scan, scan scan, but I need a I need a device for my unit. So any talking points for visiting your C suite, you know, the people who decide what you can spend money on and saying like, you know, but there's value to doing so any tips for people when they have to make that sell?

Speaker 4 46:38

I, I think I think the first best talking point is as neonatologist, we all strive to provide the best quality care to our neonates. Right, timely, effective, and evidence based care. And ultrasound is supported by all these things, you save time, it is effective. And it's evidence based using for the applications that we just talked about. And on top of that, there is an added bonus that you can build for some of these applications that have been used within neonatology Dr. Alan Gross. Like, has shared these billing codes extensively. And there are several programs which have established billing pathways for point of care ultrasound applications. So when you combine delivering the best care to your babies, as well as some benefits with billing, I think I think you can make a strong enough point to push forward things from machine. And even the machines these days are getting more and more accessible for from somewhere really small, to handheld device to a fancy machine where like you have 15 different probes in 15 different settings. So finding what fits best for their applications would be one, one of the important things and proposing that as their need is the next step. So

Ben 48:08

so a random question. I guess we have to ask this question. You go online, you see some ultrasound probes that you can connect your iPhone, is there? Should should people even look into this? Or is this a big? No, no.

Speaker 4 48:21

I think I think they're very accessible. They're handy because

Ben 48:28

they're like, they're like 2000 bucks or something?

Speaker 4 48:30

Yeah, yeah, I've, I've used a couple of probes myself. And they're accessible, they're handy. They're quick, and the quality of images are still not comparable to the big machines that you roll out or, like even small missions, Ebola. So I think they're great if that's your only option. But if you have access to a machine that can get you good quality images, or better quality images, I would I would lean towards those machines.

Jae Kim 49:06

And I'd agree, I would say that the two areas where I've seen people kind of falter is they buy a machine because whether it was flashy, or someone told them that this is inexpensive, and they they ended up buying something that doesn't suit their purposes, it doesn't have the right probe and the image quality. And even though it was cheap, it didn't serve them very well. And then the flip side is they buy like a massive, you know, they really have all the bells and whistles and they're probably only going to use 20% of the functionality of that machine. So there's there's again, probably now with a lot of companies that are out there with sort of middle ground which still has amazing image quality compared to even 10 years ago. You can you can get a very good device that may not be the supreme cardiac device, but it's going to give you a mate using linear images for 85 90% of the techniques that are going to be bread and butter every day that you're going to be using in in the unit. I think that's, that's important. The other advocacy, I remember we were able to leverage the fact that nursing and particular nurse or pick team nurses now that the vascular access teams are coming into the NICU with ultrasound, it wasn't the case before. And that's a nice area where you can advocate for having a device, because you want you want vascular access teams to have access to these ultrasound machines. And we were able to get a machine in San Diego on that basis that ultrasound is here. And we had a bunch of nurses trained. And so they were able to advocate for a machine. For that reason.

Ben 50:53

I wanted to switch gears a little bit because, Jay, you're the Director of the Division of neonatology at Cincinnati Children's, we don't really get the opportunity to speak to someone of your caliber every week. So we wanted to take the opportunity to ask you a little bit about your role at Cincinnati Children's. And I think the reason we want to talk to you about this is because there's probably a lot of neonatologist out there who are listening to the podcast, who maybe in the back of their mind or thinking, hey, in the future, if if opportunities for promotion within a department present themselves, I may be interested in taking them on. But we really get no training as to what the expectations are. I feel like these opportunities sometimes land on your lap, they're like, Hey, do you want to interview for this position? And you're like, sure, and and there's no real prep that's being done on the front end unless you were unless it's in within your own division, and you've sort of grown under the tutelage of your current director. And in your case, specifically taking on the directorship at Cincinnati Children's is a monumental task, you've been very successful, and I am, we don't know each other very well. But I am convinced that when this opportunity presents itself, you must be feeling like, am I the right person for the job? I mean, am I going to do a good job? So how do you take this leap in saying, Okay, I'm gonna make the leap? And and what are the things that you're looking at when you are accepting this responsibility?

Jae Kim 52:15

Yeah, that's a that's a big question. I'll try and answer. You know, I think the thing I recognized early was that leadership does not, is not judged by title, that when you start as a professional, you're already especially neonatologist and in medicine, you're already designated a leader, you are responsible for a lot of things. And, and you're looked at in the unit, for sure, as the quarterback of the leader of the of the medical team. So developing leadership skills, and being a leader and acting like leader starts from the beginning. And I don't think we do as good a job in fellowship training, fellows, good leadership skills, and sometimes, you know, keep after just figure that out on along the way. And I think we can do more at the fellowship level. But even when you start as a faculty, I certainly thought that that's that was my perspectives I, I need to learn how to be a leader and read up on a lot of different books on what is what makes a good leader and what what are the things that I need to build on and the attributes for that? So I think it starts early. So it's not like all of a sudden you say, Oh, I'm going to take on a large role is actually a build up. So the build up comes from managing teams, and understanding how do you act as a leader, like I made lots of mistakes, trying to figure out how to be a good leader. And it's good, it's it's much easier to do that early and kind of figure out, okay, how do I interact with different groups of people? How do I, how do I get things done? And that those skills require time and maturity. So it's making sure at the early career level that you as an individual are looking at that, but also having a support system. So that there's opportunity for you the lead opportunity for you to really cut your teeth in the different areas. So you know, for instance, we have a large division, and it's really important within our division to give as much responsibility to everyone so people rapidly form into teams rapidly start generating their own area of interest and programs. And that program suddenly becomes something they're responsible for that they're leading and those programs that really pull up to the top and become really strong, then the leadership role becomes more formal. And, and they get that experience, sort of grassroots building up something from the ground from the ground up. And so I think that's, that's a good way to set you up in a career path to say, hey, it's not born to, to you to lead that that was something you continue learning and learning by example to by learning by seeing around you that everyone's got different leadership styles, and different approaches. And that's really a good way to grow into a larger role. I sent a look at all my mentors and the leaders that I both leaders I really respected and those that I did not and learn, you know, what not to do. Clearly, that was formative for me to just take take on a larger role like this.

Daphna 55:58

That was very helpful. I am, we like to ask be part of our mission at the incubator is really, you know, helping people in whatever way we can to, like, just navigate day to day life and managing work life balance and things. So certainly someone like Uj, who's leading and division, still doing your own research, getting involved in the, you know, training community. And then, say, you as well, you're pulled in all directions, I can tell from all of these outlets, especially, you know, with your kind of leadership roles in the AP. You know, how, how do you guys manage it on an on a day to day basis? You know, we think we feel this is something that we're not talking about enough as a community. So we, so we ask everybody,

Jae Kim 56:47

yeah, I'll go first. And so you can follow your perspective. I mean, I think it's, it goes back to my first perspective, like, you gotta, you gotta love what you're doing. And, and, and I think that's the start of that is, is that you're going to work hard for things that you care about, and that you're passionate about, and that you want to make a difference. You know, my personal motto has always been, make babies better. So I put it up against anything i I'm about to do and that that reference it. And it helps me as a guidepost and say, Does this do I feel like it's shaping the overall mission for me? I think that's really, really important. And then so there's that focus, and then you can put the energy into that. But having that work, what is work life balance look like for intensivist like ourselves, it's, it's not easy. You have to make really clear, organized structure in my mind for you to, to balance that it's very easy to be overworked and, and sort of lose out on some of the personal gratification. So simple things like for people who have families, I certainly made a strong commitment, right from the very beginning, that I'm going to have dinner with my family, every, as many days that I can, if I'm not on call, that was a commit didn't matter how so I'd come home, eat dinner, and then I'd have work I'm going to do work after after that. Little things like that need to be in place scheduled, organized in the calendar in order for you to really kind of balance out because our work commitment is very strong. It's very structured, very organized. And it's very easy for that to become the dominant force. So I always tell people to build some of those things in because that certainly helped me make sure that I had some balance in terms of work and work and family life.

Speaker 4 58:50

I think I think I'll take this as an opportunity to one give kudos to the work you both have been doing right, like this podcast within the past year has exploded and you're helping the neonatal community in several different ways. And this is the passion this is something you do extra on top of your work, which is it is what drives all of us right like the passion, something that keeps us up at night. The sense of helping others in the community, I think, helps us devote slightly more time towards the work if needed. But at the same time having like important time family spending time with your loved ones also should take the driver's seat and once the work work schedules turned off, and certain things I tried to do and I'm still not good at it, but I'm still training myself to be good at it is trying not to respond to work emails or even checking work emails after certain hours and that's a good one. It is hard, it is challenging, like it just pops up on Your screen one or one of these days, and you still try to respond if it's an important email, but after certain hours, nope. Like trying to turn it off and trying to turn on your life life mode and living it up is, is what I tried to do so I think, yeah,

Ben 1:00:19

yeah, that's a game changer. I agree with you. Go ahead, definitely.

Daphna 1:00:24

Now, while we're talking and thinking, you know, as we're talking about work life balance, and I think we, we talk a lot about boundaries and setting our schedule. I wonder, you know, if you guys can speak about your like relationship with, you know, just dealing with the the mental burden of the work that we do, you know, not taking home that sick baby, you know, emotionally, not just in terms of, you know, the physical time component,

Ben 1:00:53

you're saying that because your postcode definitely Yeah.

Daphna 1:00:58

Every day every. It's my struggle, right? So now I'm just gonna start to ask other people. Yeah, how they deal with

Jae Kim 1:01:07

it? It's a really good question. And it's something that one of the reasons why some people don't do intensive medicine, and particularly in the NICU is because of the high losses that we see in high pain value that we see in terms of some of the suffering that our patients have, I struggle a lot with it, too. One of the things is, it's is you want to, you don't want to be so deeply engaged, that it damaged your well being. But on the other hand, you don't want to be so removed, that you become distant and separated. So, to me, I always have that sense that I've got to feel something bad, I have to feel the burden to a certain level and control that. So it's almost like balancing on on offense. Because I can't completely go emotionally into it. And I also don't want to go the other way and not care. And so it's for me this it's this balancing act that I'm constantly checking, am I getting too deep into this? Or I'm or am I not? And it's just it's so it's a bit of reflection that I'm doing in order to create make sure that that balance is in place?

Ben 1:02:28

Am I understand this to screen? So you're saying like, the burden is a reminder that you still care?

Jae Kim 1:02:33

Yeah, it's, and I'm, maybe I'm, I've done this long enough that I can, I can sense when I'm going too far in or when I'm going to, I'm pulling away too much. But I do think that that's a sensor. For me, it's definitely an indication, that helps me guide because I need to feel it, especially if it's a terrible situation and you had a bad night, you do need to feel awful about it, it impacts we're human, when you lose a baby or when or when something bad happens and you could have done you thought he may could have done something better. It's going to impact you. And it should impact you. And it changes you. Right. So So I think that's important, but then you have kind of recover from that. You've got to you know, wake up from that. And I think your loved ones and family are amazing to help, you know, snap you back, like you could have had I have many occasions where I've had a horrible day, horrible night and you come home and you get greeted with just something completely irrelevant and you're asked to respond and and it just snaps me out of that and say okay, you know, there's another life here that I've got I am part of another world and that's that's definitely helpful to have those people around you. Say

Daphna 1:04:00

you are you doing the show for us?

Speaker 4 1:04:02

I was I was intentionally going second on this question to learn from what better answered and I still struggle with like coming home bringing it home when it comes to sick babies, babies who don't follow the plans as most of the time. But like Dr. Kim said, You come home to your loved ones and you're faced with altogether a complete totally different reality and they still allow you to share your feelings and emotions but at the same time bring you back to Hey, yep, that's you, you tried your best and and this is what comes with the job. So like I think I think having that balance is what works but I still am still in a process of bringing it back home a lot more than what I shared.

Ben 1:04:58

I love that because because I think gets like when we talk about work life balance, the balance comes from having a work but also having a life and right and I think that's what you both are describing I think it's it's, it's fascinating to say you have to develop and keep keep nurturing your life so that you could create your own balance. I think otherwise, everything tilts over.

Speaker 4 1:05:19

And the I just want to reinforce an important word Dr. Kim just used as reflection, right? Each of these moments give you an opportunity to reflect on, hey, like, is there anything I could have done better with this versus not? So like trying to reflect on it trying to learn trying to grow? Or the important take home messages from all these experiences? So? Yeah, yeah. And

Daphna 1:05:46

when you talk about reflecting, reflecting I was, I was touched by that, that, you know, feeling some of that pain with the with the families and with your patients. And having, you know, the opportunity to reflect on on how valuable the work is, and that we get to, that we get to do this kind of impactful work is really something special. So, thank you.

Jae Kim 1:06:14

I think the thing that is important to recognize when you go to the community, when you go and talk to parents and families, they have a tremendous amount of respect for our field, handling the sickest babies, and dealing with just horrible scenarios as as we do. So really have that in perspective, that there's a tremendous community that supports the work that we're doing, particularly in the innate apology, because we're at that cusp of viability, we're, you know, really dealing with some very, very awful scenarios. And people speak so highly about this area, whenever you talk to people in the community. So that's, that's also really helpful to, to balance out the painful times.

Ben 1:07:04

Well, I think this is a good place for us to close out the show Daphna J Tsai, thank you so much for coming on the podcast today and for sharing your knowledge for sharing your experiences. I think you've given us so many tools and so many tips to develop a lot of different aspects of our career. So thank you both for your time. And we'll put a lot of the links to the resources you've mentioned on our on our webpage and on the show notes so that people can actually seek out these courses and these different references. So thank you both.

Speaker 4 1:07:35

Okay. Absolutely. Thanks for the work that Ben and Daphna you both do a fantastic job with board preparation. Some of my colleagues have benefitted with it and just your journal club episodes and tips from the legends in neonatology. All those episodes are fantastic, and I love listening to all episodes. Thanks for the work you do.

Ben 1:07:59

Thank you site. Thank you. You're too kind. Thank you.

Thank you for listening to the incubator podcast. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot v dash incubator.org. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns. Please see your primary care professional. Thank you

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