Hello friends 👋

In this episode of The Incubator Podcast’s “Giants of Neonatology” series, hosts Ben Courchia and Daphna Barbeau welcome the renowned Professor Lex Doyle. With a career spanning over 40 years, Professor Doyle shares his journey through the transformative eras of neonatal care. He reflects on the evolution of neonatal practices, his pioneering role in the Victorian Infant Collaborative Study, and the critical importance of long-term follow-up research for preterm infants.

Professor Doyle discusses his early experiences in neonatal care during a time of limited technology and evolving approaches. He highlights the significance of collaboration, mentorship, and multidisciplinary teamwork in advancing the field. The conversation delves into the challenges and successes of his groundbreaking studies, including research on family-centered care and long-term developmental outcomes.

Listeners will gain valuable insights from Professor Doyle’s reflections on the balance between clinical work and research, his dedication to improving neonatal outcomes, and his advice for young neonatologists navigating their careers. This episode offers an inspiring look at the profound impact of one of neonatology’s most influential figures.

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Lex William Doyle, MD BS MSc FRACP: Professor Doyle has worked in the field of neonatal paediatrics for more than 40 years. He was first appointed to the Department of Obstetrics and Gynaecology in the University of Melbourne in 1978 and worked exclusively in neonatal paediatrics until 2006, when he stopped working in the nursery at the Royal Women’s Hospital. As well as training in Melbourne, he was fortunate to work and train for 3½ years in Canada, at McMaster University, where he met and worked with many esteemed international colleagues in neonatal paediatrics. Professor Doyle has major research interests in evaluating neonatal intensive care, including how to improve on that care, and its economic consequences. He is or has been a chief investigator on many randomised controlled trials of interventions designed to improve the outcome for the tiniest and most immature babies. He leads or has led several research groups interested in the outcome for tiny babies well beyond the nursery and into adulthood; these are the Premature Infant Follow-up Programme at the Women's, and the Victorian Infant Collaborative Study Group. As a consequence of his research activities he has over 470 scientific publications, one book, and two completed theses (MSc [McMaster]; MD [Melbourne]) to date (2017). In addition to his research activities, Professor Doyle is now Associate Director of Research at the Women's, and is heavily involved in undergraduate and postgraduate clinical research education, mentoring, and supervision.

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

[00:00:00.800] - Ben Courchia

Hello, everybody. Welcome back to the Incubator podcast. We are back this Sunday for a new episode in our series on the giants of neonatology. We're very excited. Daphna, how are you?

[00:00:13.280] - Daphna Barbeau

I'm doing great. You know, I don't even. Why do you want to get into the banter? Because we have been very much awaiting this guest and we love the Giants series.

[00:00:24.350] - Ben Courchia

So we're very honored to have with us Professor Lex Doyle today. And to be honest, I've been thinking about scheduling this interview for several years, but I thought the podcast had to be big enough to match the, the, the, the aura of.

[00:00:38.250] - Daphna Barbeau

I'm not sure we're there. I'm not sure.

[00:00:39.530] - Ben Courchia

I'm not sure we're there, but here we are. I feel silly even going through your bio. You're one of the few neontologists who has his own Wikipedia page. So that, that's kind of cool. But for the people who may not be familiar with who you are, I'm going to quickly mentioned that you're currently the Associate Director of Research at the Royal Women's Hospital and you're actively involved in clinical research, education, mentoring and supervision of both undergraduate and postgraduate students and trainees. Professor Lex Doyle has dedicated over 40 years to the field of neonatal pediatrics and neonatology, making significant contributions through his research on improving neonatal intensive care and its various consequences. He's led several research groups focusing on the long term outcomes in premature infants and has authored more than 470 scientific publications, books, theses, and much more. Professor Doyle, thank you so much for being on with us today. So my first question for you today is really going back to the inception story of your career in neonatology and ask you what really prompted you to pursue this field at the time you did, especially considering that it was a very different field than what it is today.

[00:02:02.650] - Lex Doyle

Yeah, thanks very much. It's a good question. I went through the public system in terms of education in Australia and then went to medical school straight from high school, which at that time comprised six years at. At which time I graduated in 1972 at the ripe old age of 23 years. And so it was that age when I was out looking after adult patients in my intern year. But I then went on to do pediatric training and I was interested in doing pediatrics during my undergraduate years because I felt that the pediatricians had more empathy and it just looked like a career for me at that stage. It wasn't neonatology because in fact we got exposed to very little of neonatal care as an undergraduate. But during pediatric training, of course, we had to do a fair bit of neonatology. So again, at the time when I was training in the early 70s, the duration of pediatric training was five years. And I went to the Royal Children's Hospital in Melbourne, which is one of the big centers in Australia, to do pediatric training. And in the second year, half of the training is basic training.

[00:03:18.350] - Lex Doyle

Halfway through, you sit and exam what you would call your clinical boards, and if you pass that, then you can go on and do advanced training. And in the second of the basic training years, I was rotated to the Royal Women's Hospital in Melbourne, which is one of the largest of the three perinatal centers in Melbourne that had an neonatal intensive care unit. And I was there for four months and all the clinical training was very heavy in a sense of the clinical load. And on a quiet week, we were rostered in house only for 78 hours. And on a busy week, which was two out of five, we were in house for 126 hours per week. Remember, there's only 168 hours in a week. So we basically lived in the hospital. We were just starting to ventilate babies or small babies. Just a few years earlier, no one had been particularly trained in how to care for small babies. We had three little square ventilators built by Luz & Co. From Amsterdam, and one baby bird, the baby bird. Unfortunately, no one really understood and we tried very hard not to use it. And so it was effectively just three ventilators.

[00:04:34.840] - Lex Doyle

And the babies needed to get to be pretty sick before they were intubated. So they might get up to 80 or 90% of oxygen received via an oxyhood before being intubated in the ventilated, you'd never do that today, but by the time they got ventilated, they had.

[00:04:51.610] - Ben Courchia

You were really dreading. You were really dreading to having to put these kids on the ventilator.

[00:04:56.080] - Lex Doyle

Exactly. They had really severe ideas by that stage, and most of them would have had a whiteout on a chest X ray, which I suspect very few people see today. Part of the reason they had such severe lungs, lung disease was because they were born inadvertently too early. And this particularly applied to infants of diabetic mothers because there was a big problem, and there still is a problem in obstetrics today, that infants of diabetic mothers, particularly insulin dependent women, their babies tend to suddenly die towards the end of pregnancy. And so obstetricians and physicians caring for the mothers were very worried about These babies, and so they had a policy of delivering them all at 37 weeks. The only problem was they didn't always get the dates right. And this is an era before routine early antenatal ultrasound dating. And so sometimes the dates were out and typically out by a month or so. So Instead of being 37 weeks, here are these 33 week infants being delivered by elective cesarean section in the situation of maternal diabetes. And they had the worst lung disease of all. So the pressures we had to use would be sometimes as high as 50cm of water.

[00:06:09.740] - Lex Doyle

And again, I doubt you would see those pressures used much today. A combination of all this, not surprising, air leak was very common and more than a third of babies would develop at least a pneumothorax. And you got very quick, you got very slick at diagnosing and treating a pneumothorax. You suspect it shut off the lights, put on a bright light and transilluminate and then gesture would all be done within a couple of minutes. So we just got very quick at doing that because we had to. The babies would crash big time. So of course, ear leak went everywhere else. The other interesting thing at that particular time, because of no antenatal ultrasound, you would occasionally be trying to resuscitate babies that turned out having Potter syndrome. In other words, no kidneys and very small lungs. And of course that was very interesting because they just didn't respond and of course they died. And other things like congenital diaphragmatic hernia were undiagnosed neonatal and some of those were really sick at delivery as well. Anyway, halfway through the training I did get the exam passed and in my last year of training I decided I would go to the Royal Women's Hospital again, having completed all the other aspects of pediatric training, to become what you would call a neonatal fellow today.

[00:07:32.540] - Lex Doyle

It wasn't called that then, but this time I did have a bit of a reduced burden of clinical load because by that stage they'd appointed two more house staff. So I only had to work one 24 hour shift in the unit and another 24 hours I covered both the unit during the day and then I was on for the transport service. So the clinical load was reduced, which meant I had time to think for the first time about research.

[00:07:58.600] - Ben Courchia

Professor Doyle, your career has been deeply rooted in collaboration and mentorship, from your work with the Victorian Infant Collaborative Study to mentoring young researchers. Given your extensive experience, what do you think are the most important qualities of a successful mentor? And how can early career neonatologists build meaningful collaborations across disciplines to advance neonatal care.

[00:08:21.390] - Lex Doyle

I had a mentor, Bill Kitchen, and he's an interesting guy because in the 60s he had done a randomized trial of intensive care versus non intensive care. I mentioned already that the standard of care for babies in his 60s was pretty much to ignore them for a couple of days and if they then survived, then you might do something like feed them or whatever. You kept them warm, you might have given them oxygen that was unmonitored, but basically they were left alone. And Bill said, well, what about we put in an umbilical catheter, we can measure blood gasses, so at least we can monitor the oxygen therapy and we can use this to infuse glucose. And at the time bicarbonate was useful and had been shown to increase survival. So he did this trial of what he called intensive care, but there was no ventilation then. And he showed that, yes, it did increase survival if you gave this package of monitoring oxygen, giving glucose, et cetera, versus not doing that. But he also had the foresight to say, well, if we're going to do that, we need to know what they're like long term.

[00:09:26.990] - Lex Doyle

And when he followed them up, he found that there was more handy what the word he used was handicap at the time, what you would call impairment or disability today in the survivors. So there was always this potential problem, increasing survival but increasing the rate of handicap disability in the survivors. So he then established further cohorts in the 70s and late 70s, early 70s and late 70s, which he then wanted to follow because as they started to ventilate babies, the survival rates started to go up. And he was, he had these data accumulating from different cohorts at different times. And he started to feed me what I would call scraps of data. He knew I had some statistical skills and methodological skills. He'd never been trained in it, he'd learned it on the run, but he started to ask for help. And so that started a collaboration between he and I, which was very productive.

[00:10:24.740] - Ben Courchia

Yeah, he played an important part in your, in your career.

[00:10:27.950] - Lex Doyle

Absolutely. He was, he and Jack Sinclair were two very important mentors for me. Now, Bill's work actually led to the creation of the Victorian Infant Collaborative Study. Because there are only four neonatal units, the intensive care units in the whole state of Victoria. They're all based physically in Melbourne. At one stage, they're all within a couple of miles of each other. Subsequently, two of them have moved further out of town, but it was just a very sort of very tight knit package. These were the only places where if you were a very tiny baby, you were going to survive. Three of them were in maternity hospitals and one was in the standalone children's hospital. So it was the maternity hospitals in particular who saw most of the tiny babies. And the only ones, the only tiny babies that ever got to the children's hospital were those who we caused problems like we perforated their gun or they needed a cardiac operation or something like that. So they'd end up at the children's hospital. But the other three, they got together and this and created the first Victorian cohort that were born in 1979-1980. And there were a total of 89 survivors under a thousand grands in the state over those two years.

[00:11:40.600] - Lex Doyle

Just to show you how many there were, there weren't that many. So having established the Vicks cohorts, it didn't become called VICs until the mid-80s that it was. The co ops were created and Bill and I worked on that and then he retired in 1991. And then I took over leadership of FICS, the Victorian Infant Collaborative Study Group. And the other centers were happy to cooperate with that. And that's the longest running program evaluating intensive care that goes, dates back from the late 70s and it's still going today. We have cohorts through the 90s, through the 2000, 2010 and our most recent couple, 2022, 2023 have been recruited but we'll start seeing them at two years later.

[00:12:31.890] - Ben Courchia

And the papers keep, keep being published from this collaborative and they're, and they're always of high quality. Looking back over your career, I think it's interesting. We take care of so many babies and we feel like we have this privilege of making a difference in families lives by helping them with one of their most vulnerable moment. But for people like you, who have such an extensive career, both on the clinical side but also on the research side, do you feel that what defines your career is the impact of your research activities even more so than the clinical work, or do you feel that nothing really can compete with the immediate impact of neonatal care on an individual basis?

[00:13:23.290] - Lex Doyle

I think you can't separate clinical from research really as a clinician it was very clear that the longer term outcome for the baby was going to be determined very much by the family into which the child was going. So if you were to spend all your focus on the baby at the expense of the family and not give them the ability to cope with that child, then you're really wasting your time because that Child would go home to an environment that was not favorable and do quite poorly. And I don't know whether, you know, but back in the 50s and 60s, I think it was parents were banned from nurseries because they were deemed to be dirty or carry infectious diseases. And there were instances where mothers, for example, may not see the baby from birth until the time the baby was ready to be discharged, time maybe two or three months later. You can just imagine the impact that would have on a poor mother and the rest of the family and the ability to cope with her child. And so examples of child neglect and child maltreatment were rife in the 50s and 60s from that era.

[00:14:38.270] - Lex Doyle

But fortunately by the time I started, that attitude had long disappeared and families were very much encouraged. And so always the emphasis was have the family involved in the care of the child. Today it's taken much further where the mothers and the fathers and other family members are often in nurseries actually doing physical things part of their care. But that wasn't going on back in the 70s and 80s, but it was still the family were part of the team. So the research has, our research has tried to include families and more recently we've actually developed some interventions through the family to help the child in terms of their long term outcomes. And we're having some success there, but not, it's slower than I would like to see. But you know, the family's always been critical in terms of the outcome for the child.

[00:15:36.100] - Daphna Barbeau

I mean, I love that you're bringing this up. This is a concept that's super important in my professional career and you know, family center care. Families being at the center of care is not a new concept, but it seems like we still really struggle to engage and empower families. And I wonder, through your clinical work, through all your research that includes families, what do you, what do you think is the secret to helping families feel comfortable create a culture where they have that opportunity to have the greatest impact on their baby?

[00:16:13.980] - Lex Doyle

Well, I think you need to talk to them first. That's pretty, pretty fundamental I have to say. Back in the 70s when I was doing my clinical training with those horrific hours I described, there wasn't a lot of time to talk to anyone, much less the foremother and the father. So fortunately these days time is more available for those activities. So you need to ask them what do they want? And fortunately there are people around the world who are exploring this big time and getting families opinions. What concerns you rather than what concerns me as the doctor or the nurse or at the bedside because parents have different views to what the medical staff have. So you need those views as well. So you need to talk to them and find out what it is. And it won't be the same response for every mother, whereas one mother will be different to the next one and then what, farther to the next one as well. So you have to individualize these things. And there's no one size fits all.

[00:17:21.890] - Ben Courchia

Interestingly enough, as I was telling you off Air one, I mean, I'm a big fan of your work because I think you are kind of the utilitarian neonatologist. You want to find out what each pathology in terms of what is its impact on the functioning of the infantry long term. And I'm wondering if you mentioned that some of the people you met along the way really opened the door for you to think about it in those terms. But can you tell us a little bit about how our thinking of what long term neurodevelopmental outcome really means, from the early 80s, where you were beginning in the field, to where we are today? What do you think of how our thinking of long term neurodevelopmental mental outcome has evolved? And do you think we're there yet or is there more work to be done?

[00:18:15.090] - Lex Doyle

It's interesting that the long term neurodevelopmental outcomes haven't really changed a whole lot. What I mean by that is if you look at a bunch of children from, say, the 80s, and you compare them with a bunch of children today at the same age and assess them, you find that the rate of neurodevelopmental impairment overall compared with children who were born on time. That's always important to have a comparison here so that you can adjust the various tests, et cetera, but you find that the overall rates of impairment are much the same. They're always increased in the X prems compared with the controls by a certain amount. And that really hasn't budged that difference over a long period of time. What has changed, of course, is there are far more survivors who were born very tiny who are around. So the neurodevelopmental aspects haven't really shifted all that much. And we need to be doing more work to try to reduce the rates of those impairments and disabilities. But what I must say is that we've looked beyond just neurodevelopmental impairment to looking at other outcomes, particularly to do with the rest of the body function, but also the function of the child in the community and within the family, and particularly as they get older.

[00:19:33.900] - Lex Doyle

So you're probably aware that some of our cohorts from the early years we've followed into adulthood and transitioning into adulthood is pretty critical. What job do you do? Are you happy? Do you have relationships? Are you still living at home? Those sorts of issues are very important and we've been able to establish that. Fortunately, in terms of transitioning to adulthood, some of our most recent cohorts that we've followed into adulthood, they seem to be transitioning pretty well compared with controls. Now, of course there's ups and downs and one of the problems with following cohorts into adulthood is that you don't always get to see 100% of them. So as they get older there are progressively more that you don't see. And there's always the worry that those who you don't see other ones who are having more difficulty and almost certainly they are, but the difference, the problem there is you just can't quantitate it. So all I can say is of the ones we see, they're doing pretty well.

[00:20:39.050] - Ben Courchia

A little bit, yeah, a bit of survivor survival bias almost where you're, you're only seeing the people who are doing relatively well. Um, it's interesting, I was asking this question because I felt like reading your papers over the years. I've been reading your papers since I was a resident and it seems that you have found a lot of values, value in studying and the information we're, we're gathering from babies late into childhood, couple years of age, whether it's five years old, six years old. And I see more recently that you're publishing a lot on babies with bronchopulmonary dysplasia. What are their five year, six year outcome? Are you, are you getting more satisfaction from that data than the traditional Bailey three at like two years of age?

[00:21:32.190] - Lex Doyle

Oh, absolutely. The longer term data are much more informative than the standard Bailey or tapping of knees and establishing whether they've got cerebral palsy at 2. I mean you can get a lot of information from a 2 year old or a 3 year old, but you get far more from a school age child and even more from an adolescent or an adult. So, you know, the longer you can follow and establish outcomes, the better. But the trouble is you can't always afford to wait. And neonatologists are very impatient. They want to know what the baby today in my nursery is going to be like in 20 years time. Well, you can't tell them until they get 20 years old. You can't be sure.

[00:22:16.650] - Ben Courchia

And by the time they are this old, the target has already shifted in a NICU where we're behaving in a very different manner.

[00:22:22.330] - Lex Doyle

Right, but, but the data from 20 years ago to 20, the 20 year old who is today 20, born 20 years ago, is still relevant to today's nursery until they're supplanted by more data. So the data aren't useless, they're still informative, but they do change. And neonatologists are impatient. They're always fiddling with things. I stopped working in the nursery in 2006, so I can be disparaging to neonatologists because I'm no longer an active neonatologist. But they always want to fiddle and they always want to change things and they think, well, you know, the baby was better at two days of age, therefore what I'm doing must be good. But I have to keep saying to them, hang on, it may not be so. It may be that, you know, in two or five or 10 or 20 years time, what you did today may not be so good. You won't know that until you follow them up. So, you know, it's, it's a, it's always shifting ground, if you like. And I'm only joking when I'm saying I'm disparaging to neonatologists, but you have to have a longer term view is what I would say.

[00:23:37.020] - Daphna Barbeau

And then I had another question about the focus on development kind of over the last handful of decades. I feel a lot of what we're doing in neonatology in terms of follow up is looking at kind of these major interventions we do in the first few days, two weeks of life and then seeing what happens based on a medication or based on a ventilatory mode. And I wonder what you think about actually studying like developmental interventions in the NICU as opposed to seeing what happens in follow up based on, say our quote, unquote medical interventions.

[00:24:18.650] - Lex Doyle

Yeah, we've tried to do some developmental interventions starting in the NICU and then continuing after families go home. And we did a randomized trial. Oh, that goes back almost 20 years now, when the funding was available, where we sent a physiotherapist and a psychologist to the family home randomly allocated and tried to give parents the skills to see if they could improve not only the child's development, but also improve their own mental health. And the results of that trial were interesting. It did improve parental mental health and it improved child behavior at two years, but it didn't improve the Magical Bailey score. And when we followed the children up, it didn't improve IQ longer term, but it also translated into improved outcomes for families. But the trouble with that intervention was it wasn't a real world intervention. You can't send psychologists and physiotherapists in a family home eight times over the first year. It's too expensive. You don't and you don't have the staff to do it. So we then adapted it to say, okay, well what about if we try to do this through a web based intervention and again, try to do a randomized trial.

[00:25:37.440] - Lex Doyle

When I say try to do a randomized trial, these trials are difficult to get funded and to recruit for, so you end up with fewer participants than you would like. But again it showed that there were some improvements for parental mental health and potentially for child behavior. But again, the intervention still wasn't real world, but that's now been adapted to a more telehealth type approach. And we're actually doing a random Australia now which is recruiting quite well. And those results hopefully will be available in a year or two. When I say with this is the collective we I'm part of the team, but it's being led by others. And one of the good things about getting old is you see these younger people come through who then take the research in their own direction. And this particular field of research has been led by a physiotherapist called Alicia Spittle who's based in Melbourne and that's her team that are leading this research and she's developed a whole bunch of interventions to try to improve long term outcomes for both child and family through those sorts of things. The intervention starts in the nursery, but it continues beyond discharge.

[00:26:46.950] - Lex Doyle

And I think that's critical that we need to be looking more at interventions after they go home. Even as neonatologists, we have a responsibility for the long term outcome for our children.

[00:27:01.000] - Ben Courchia

I wanted to ask you a little bit about what you just mentioned, which I think touches on the concept of audacity where and you've really never been afraid to jump in and really tackle something that has been difficult. I mean, to me you're a great example, especially when it comes to steroids, where your work on the DART study was so influential in how we view the use of steroids when it had been this pendulum that swung all the way back and forth and long term brain outcome and so on. I'm just curious as to do what gives you the strength to overcome the inertia of tackling these subjects and how do you instill that in your team as well? Because I Think from the Victorian collaborative, we see that coming with very compelling papers every couple of months.

[00:27:56.910] - Lex Doyle

Well, I remember someone saying, quoting, I think a school of new graduates where the, where the person at the ceremony said, well, good news is that half of what you know is correct and half of what you know. And the bad news is half of what you know is incorrect or is causing more harm. The trouble is you don't know which half is which. And this applies today as much as it did whenever the, those words were said, you know, 40, 50, 60 years ago. And although what you do today you might think is all correct, almost certainly something's going to end up in the future, being people look back and say, well, why the hell were you doing that? That's wrong, you were causing problems. And so you've always got to have this skepticism. And unfortunately the majority of what we do in the NEO intensive care unit isn't evidence based. If you go back to try to find, well, what evidence supports what I'm doing in this particular instance, you often find it just doesn't occur, it's just not there. That's not to say it's wrong, I'm just saying it's just not evidence based.

[00:29:09.500] - Lex Doyle

So you have to always have this questioning attitude. Is what I'm doing today in this particular instance correct? And if you're not sure and you've got reasons to doubt it, then I think you've got to have the ability to say, well, we need to ask the question and test it in a randomized trial. It's the only way to make progress. How do you instill that in younger people? I think you do it by example. Clearly you've got to be consistent and you've got to have the young people who will be prepared to actually help you in answering these particular questions. Because you can't do this by yourself. You do need lots of collaborators, what I call friends and those friends tend. Of course, I'm pretty old now, so they're all younger than me. So you need a lot of younger people, you need to instill the same skills in them as you have developed yourself.

[00:30:06.490] - Daphna Barbeau

It looks like collaboration has really been a theme in your life and in your career through the collaborative, but doing long term outcomes for hundreds of research groups. And I wonder what advice you have for people who are trying to collaborate. You know, we're trying to cross state lines, cross international lines, but you've been doing it for decades. So what advice do you have for people?

[00:30:34.910] - Lex Doyle

Well, you can't have a big ego, it's important that you are not a dominant sort of person that says doubt shall be done this way. And that's the only way to do things. You have to listen to what other people want, but you have to make it something that's advantageous for people to collaborate. And so I think most people want to help and if they can gain something from it with respect to learning skills and gaining credit for what their activity, I think that's enough to encourage most people to help out. And I think once you've established a group, you need to be always thinking of, well, what other things can we do to bring people in? And it's important that it's a multidisciplinary group. Vicks is not just an neonatologist, it's psychologists, it's physiotherapists, it's occupational therapists, it's nurses. As the children have got older, we've included respiratory and cardiac and other imaging type outcomes. So you need skills from lots of areas and you can't just keep it medically focused. It has to be multidisciplinary. And that's why I think it's so successful, because people from other disciplines actually gain a lot from learning from medecos and the medicos gained a lot from learning from the ancillary services.

[00:32:00.460] - Lex Doyle

I've learned so much from psychologists and physiotherapists and occupational systems therapists and nurses and other people that I've come across far more than I've learned from medical people. So I think you have to have the ability to think beyond your own comfort zone and encourage those people to come into the fold.

[00:32:20.810] - Ben Courchia

I'm wondering if this mindset is what prompted you to be such an early adopter of new technologies. I think you've always been someone who has tested new technologies, new interface, new tools. Is that something that really was deep seated early on because of these experiences or do you just. Are you just somebody who likes gadgets and loves to innovate?

[00:32:44.370] - Lex Doyle

Oh, I'm definitely not a gadget person. I'm the last person. The reason I stopped working clinically was because the ventilators were becoming too complex for me. I told you about the initial ventilator was basically on, off, change the pressure, maximum rank was 60. That was about it. And then of course, these machines come along today. They've got pressure, they've got volume, they've got flow, they've got all this sort of stuff. And that was just getting too hard for me. I didn't have the time to devote to the NICU to want to concentrate on that because the research was just expanding in other directions. So I stepped back from clinical work and unfortunately, neonatal intensive care is a young person's game. You can only stick at it for a period of time before the technology escapes you. And you have to recognize before other people recognize that it's time to get out. In other words, you don't want to leave it until you become a burden on the NICU before you get out. So you get out before you get to that stage. You recognize it in yourself before others recognize it and say, okay, time to stop.

[00:33:53.840] - Lex Doyle

So I haven't been a gadget person, but there had been other people around who I would call gadget people. We had a guy called Colin Morley come from Cambridge to Melbourne, worked with us for 10 years from the late 90s to the late 2000s and he had a million ideas and he was really keen on ventilation. He was the one who brought the Dragon ventilator to our unit and he used to love fiddling with it, but he then encouraged a whole bunch of other younger people and there are a whole group of people from Melbourne. Peter Davis is the classic example. Over many years has done lots of short term trials to do with, you know, CPAP or, oxyhood or high flow, low flow, all these sorts of stuff. And they've had great success in publishing these in high impact journals such as the New England Journal. So, you know, other people have been doing that, it hasn't been me. So I can't claim credit for being a gadget man and, and innovating, but I have been able to sort of direct them into asking appropriate questions if you like. So that's. Maybe I've had a little bit of influence, but I haven't been a big part of that.

[00:35:07.120] - Ben Courchia

So it's a bit like neo netizens, a bit like a sitcom you want to leave at your peak, you don't want to be canceled by the network.

[00:35:14.000] - Lex Doyle

It's always the same in everything. And those peak sportsmen who, they leave it one year too late or sports people, that's right, they retired. They should have retired the year before. They don't realize.

[00:35:25.940] - Daphna Barbeau

An interesting topic. We have some, they call them well established neos here in the American Academy of Pediatrics, our weekend group. And actually they've written to us about talking about phasing out of a career retirement. But you call yourself retired, but you're really not retired, you're still quite prolific. And so I wonder if you can talk a little Bit about this opportunity that you seem to keep taking about kind of reinventing yourself and reinventing your career.

[00:35:55.390] - Lex Doyle

Well, why the brain keeps working, you want to, you want to keep using it because you don't use it, you lose it. And I'm at an age where dementia is on the horizon. So if I can still be productive, I'll continue to be productive until I can't be anymore. So yeah, there's always, it's interesting about research. I think every time you answer a question you generate ten more new ones. So you can never stop. In terms of a research career, I've retired in that I don't get paid anymore. But the brain hasn't switched off. So the younger people still want me to help in one way or another. So while they still want me to do that, I'll continue to do it. But in terms of reinventing, I think it's just a question of pursuing what seemed to be the most useful thing, thing you can do. And I don't think there's any way to decide that. I've been interested in the lung mainly because of the injuries that we caused early on. And that's why I've pursued lung function if you like, longer term intermediate trying to work out what's going on because unfortunately it looks like a lot of our ex prams are they must be going to have a high rate of chronic obstructive pulmonary disease earlier in life on the basis that they're just not reaching the peak airflow in the early 20s, which what happens to normal people.

[00:37:15.300] - Lex Doyle

So their longer term future worries me. I won't be around to see it myself. But we need to know and we need to try to intervene if we possibly can. The only successful intervention I can ever think of would be to not ever smoke. But apart from that, I think there's little in the terms of treatment options. But we need to be mindful of this going back to the nicu, that we need to be always considering the long term, long outcome, whatever, whatever innovation we're doing in the nicu.

[00:37:49.470] - Daphna Barbeau

I love that we've talked a little bit, a lot actually, about some of the challenges that neonatology has overcome since the beginning of your career. I wonder what you think are kind of the greatest obstacles that neonatology is facing or will be facing in the, in the next decade.

[00:38:09.930] - Lex Doyle

Yeah, I think in terms of challenges, I think of oxygen. And oxygen is an amazing molecule. We all need it to survive. And it's been around in. Because now going back almost a hundred years, I still don't think we know what we're doing with oxygen. And I still don't think we know what we're doing with oxygen monitoring. And I say that because in the 70s we had no monitors in the sense of oxygen. We could do blood gasses and put them in blood into a machine. And then people came along with transcutaneous PO2, which was good, but it was fiddly. You had to move the probe every couple of hours because it always burnt the skin, because it heated the skin to 43 or 44 degrees and you had to move it, otherwise it would cause a more severe burn. And then unfortunately, I say unfortunately, oximeters came along in the late 80s and they basically usurped all the other technologies. But I know that babies don't need oximetry to survive. I know they don't need oximetry to monitor their longer term apneas and other misbehaviours that they do in the nicu. Because I saw, I manage babies that way without oximeters these days.

[00:39:22.710] - Lex Doyle

Oximeters, they aren't go onto a baby from birth and stay on forever even though the baby's in air breathing normally.

[00:39:31.750] - Daphna Barbeau

And doesn't need any basically till they're being wheeled out. Right.

[00:39:35.160] - Lex Doyle

And they need us, they need an operation to actually have the oximeter removed before they go home. And it's never logical to me. I don't understand why that is necessary. But if you ever try to change it, you can't. Baby's got to be on an oximeter. And just the oxygen oximetry story, to me, I think is an ongoing problem that I don't think ever is ever going to go away, unfortunately, because it becomes standard of care. And it's very hard to withdraw a standard of care. It's much easier to assess a new standard of care than it is to assess taking away a standard of care. It's always very difficult to do that. So I think that's a challenge. I don't think it's going to be solved, but I think that is a challenge I throw out there to younger people listening to this podcast.

[00:40:25.780] - Daphna Barbeau

And then I know our time is running short. I'll end with a silly question. You've worked with hundreds of teams, hundreds of papers. I wonder if there was a study that I don't want to say was your favorite, but one that really sticks with you, really impacted you, really enjoyed working on something like that.

[00:40:52.340] - Lex Doyle

Well, all the cohort studies have been my favorites in a sense that I think we've gained a lot of information but in terms of randomized trials I've been involved with, I think the very first one I was involved with may not be in your consciousness, but it's a randomized trial of oral gamma globulin to prevent rotavirus diarrhea in babies. This is a trial we did starting in 1978 when I was. I went back to the Women's Hospital for a year, and I'd worked previously with a gastroenterologist called Graham Barnes when I was doing my training. And at the time. You may not know this, but rotavirus was first discovered in the feces from babies at the Royal Women's Hospital. It was discovered in the mid-1970s by a lady called Ruth Bishop, where at the time, babies used to stay in hospital with their mothers for about a week after delivery, or 10 days after a cesarean section. They were put into communal nurseries and only brought out to the mother for breastfeeding. Go back into a communal nursery where there was next to one another, rotavirus spread easily. Rotavirus diarrhea was very common. That's why it was discovered in that environment.

[00:42:08.750] - Lex Doyle

And Graham Barnes had come along and discussed with Bill Kitchen. He read a paper on oral gamma globulin preventing rotavirus diarrhea in lambs. He thought, well, why don't we try this in humans? So cut a long story short. We did a randomized trial of oral gammaglobin in humans, and, yes, it prevented rotavirus diarrhea. And this was published in the Lancet in 1979. So that was the first randomized trial I did. And when I was at McMaster, I did the training program for the Master of Science. I told him one of the things I did was design a trial of oral gamma globulin to prevent necrotizing enterocolitis. Now, you're very familiar with neck and you know how bad it is. And so if it prevented rotavirus diarrhea, why wouldn't it prevent necrotizing enterocolitis? So I spent a whole period of time writing up protocol and putting in a grant application. I got back to Australia in 1983, applied for this money to do this big grant. But if you remember what was going on in the early 80s, there was something very nasty happening to young men and it was also happening to people who've had blood transfusions and people like hemophiliacs.

[00:43:25.830] - Lex Doyle

And it turned out, of course, it was HIV. It wasn't known as HIV at the time, but the trial we had put together was really very sound, but it was very clear we were going to be using a multiple donor blood product to answer a questioning little babies. It was clear that we had to withdraw that project because otherwise we would have almost certainly been passing on HIV for little babies, which would have been an absolute disaster. Disaster. So, you know, the oral gamma globulin for rotavirus area was fantastic. But you might think, well, we don't have to do that because the best way to prevent rotavirus diarrhea is keep the baby with the mother. The mother gives a lot of rotavirus antibodies through the breast milk. And that was the way we eliminated rotavirus diarrhea from the baby, from the nursery, from the hospital. But we didn't have to give them oral gamma globulin. But the story with necrotizing enterocolitis was a big lesson to me. You got to be careful what you're doing. And that trial was actually done about 10 years later and it didn't work. And why didn't it work? Because Nick is so sporadic and, you know, very.

[00:44:35.700] - Lex Doyle

Once you start to study disease, it disappears sort of thing. And so they just weren't powered to find an answer for it. So that's my favorite story, I suppose. But there are lots of individual studies that I've done I think are really important.

[00:44:50.440] - Ben Courchia

It's pretty cool when your first RCT makes it to the Lancet. I mean, that's, it's a, it's a. It's a pretty hefty goal to, to match my. My last question for you, Lex, today really relates to. And then we spoke about well established neonatologists, but young career neonatologists, the people who are entering the field after training. I think there's a lot of soul searching happening right now amongst young graduates about what should I pursue, how do I devote my time? And without asking you to answer these complicated questions, I'm just wondering when. What is the advice you have for people in general who are coming to you with these types of questions about the direction to give their career? I'm just curious, what is the Lex Doyle consult looks like when it comes to that?

[00:45:35.240] - Lex Doyle

I don't think I've ever delivered such a consult in recent time. So I have to make it up, I suppose. But to me, clinicians are always asking questions. We should be questioning what we're doing. We shouldn't just accept that everything we do is perfect. And I think most clinicians are like that. And then that raises questions. But you've got to be able to ask answerable questions. These are questions that are important, that have a structure and they're possible to achieve. And the way to go about that is to establish work with groups who actually do that so you can learn from them as a younger person. And once you've got the skills yourself, then you can start to ask your own questions or work with a group. But you need lots of collaborators. You need lots of friends. You can't do it by yourself. So the best piece of advice I can give to a young neonatologist is don't think you can do it by yourself. Ask for help. And the more help you get, the more productive you will be, the quicker you will get the answers that you need, and it will become more satisfying to you and to all the people who work with you and as well as to all the families and babies that you deal with.

[00:46:47.710] - Lex Doyle

So ask for help early. Don't leave it until later. Don't think you're the expert. You know, don't have a big ego here.

[00:46:55.200] - Ben Courchia

I think this is a perfect way for us to end this fabulous conversation. Lex, thank you so much for making the time to be on with us. This was a pleasure to pick your brain on such a variety of subjects. It was really great. Thank you. Thank you very much.

[00:47:10.520] - Lex Doyle

Well, thank you both. It's been a wonderful time for me, and I really enjoyed it. Thank you.