Hello Friends đ
In this weekâs episode, Daphna hosts a powerful roundtable featuring Drs. Kerri Machut, Milenka Cuevas-Guaman, Emily Miller, Christine Bishop, and Christiane Dammannâleaders of a national effort to improve neonatology staffing. Together, they share insights from their recently developed recommendations, created through a Delphi consensus process and supported by a strategic grant from the AAP Section on Neonatal-Perinatal Medicine. These evidence-informed guidelines aim to promote safer, more sustainable, and more transparent staffing models in NICUs across the country. The team discusses key themes including defining clinical FTEs in hours per year, ensuring flexible scheduling, protecting time for scholarly and administrative work, and how to advocate for systemic change. Notably, these landmark recommendations have been accepted for publication in the journal Pediatrics and will be available online in May 2025. Listeners will also learn about an upcoming toolkit designed to help individuals and institutions apply these recommendations in practice. Whether youâre a practicing neonatologist, a trainee, or in a leadership role, this conversation offers timely solutions to address burnout, support workforce well-being, and ultimately improve care for the smallest and sickest patients.
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The article covered on todayâs episode of the podcast can be found here đ
Machut KZ, Bishop CE, Miller ER, Dammann CEL, Cuevas Guaman M.J Pediatr. 2025 Jan;276:114363. doi: 10.1016/j.jpeds.2024.114363. Epub 2024 Oct 18.PMID:Â 39426794
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The transcript of today's episode can be found below đ
[00:00:00.000] - Daphna Yasova Barbeau MD
Welcome back, everybody. We've got a very exciting interview today. Lots of people in the studio, which we love to see. I think that this particular episode is going to pique a lot of interest in the community. Today, we are talking about improving neonatology staffing, and we've got some experts leading the way on staffing recommendations in neonatology on today. I did want to mention we have covered this topic a little bit in the past. If you're interested in hearing where the long road to some of these recommendations in episode 108, and also during our CHNC 2023 coverage, so you could take a listen there. But today, I have the honor of having in the recording studio, Kerri Machut MD from Lurie Children's, Milenka Cuevas-Guaman from Texas Children's, Emily Miller from Cincinnati Children's, Christine Bishop from Children's Hospital at Pittsburgh, Christiane Dammann from Tufts. We're going to have a really nice conversation today about all of the work that you all are doing to improve neonatology staffing, making things more standardized and more transparent, making things more standardized and more transparent. With us. Kari, we can talk a little bit about what group is working on this for people who don't know, and what was the need? Where did this all start?
[00:01:26.460] - Kerri Machut MD
Sure. Thanks, Beth. Not again for having us. We're really excited to be here today. Yes, I think you hit on it in the introduction that a lot of this improving neonatology staffing effort really came for trying to improve transparency in a lot of different facets of our schedule. But a lot of it also came to really help us improve the patient care that we deliver in a safer and optimal way, as well as our scientific contributions in various academic work streams that all of us, both in university and non-university practices alike, work under. But we had been hearing several years ago from many colleagues, whether it was through informal chatter or whether it was through some early publications signaling some problems with the way sappy models had evolved. I think that a lot of neonatology's issue came through a period of really rapid growth over the last couple of decades and a lot of transition of practices going from home call to in-house coverage, with accelerating patient acuity and the types of children we started caring for and who we were resuscitating and their increasing acuity and also chronic needs that then grew from there.
[00:02:38.850] - Kerri Machut MD
Really, those two seem to be coming at odds in various settings. Not at all, but certain centers were having more trouble than others and hearing that there were a lot of issues with shift length, with a lot of variability between centers and contributing to overwork and even to burnout, essentially. Our group, which started as the Women in the Neonatology Advocacy Group, was hearing about this and for various reasons that each of us had in our other lives, started to talk about this as a project topic more at length and decided to start with an annual leadership conference to the AAP, a resolution that was designed to help improve and build better sustainable and humane staffing models in neonatology. That was voted into the top 10 in 2022. With that, we to get a little bit invigorated and formed an investigator team with the five of us and really got excited and started collaborating together in building projects. We applied for and received a grant from the section of Manage Health, Caryneal Medicine, a strategic grant that has really allowed us to build on this work. Then we also, with that, formed an awesome advisor team of a lot of experts and leaders in our field that have been really great mentors to us in this process, but also really have a lot of expertise, specifically from that leadership perspective that we know is going to be really key to making a lot of the changes that our field needs.
[00:04:05.680] - Kerri Machut MD
From there, we did several pieces of different investigative work. We've done several studies. They've been presented at PAS, CHNC, and NCE. We've had a couple of manuscripts. One just got accepted last week, one of our investigative manuscripts in JPs, so you have to look for that. But the grant focus, although it was supporting that investigative work, the primary focus was really to pull all of these leaders and all this subject matter expert, if you will, together to really develop ideal state recommendations to improve staffing. A lot of that investigative work was designed to lay the foundational work for that. Then we brought everybody together in this past June 2024, at AAP headquarters in Itasca, and really got together over a two-day summit to hound these out. We did choose a Delphi consensus methodology to really make sure that the rigor that we applied in this direction was really sound because there isn't a lot of evidence base out there in the literature. We did a pretty thorough literature review, and there's just not a lot of actual evidence to support best practices. That's why we chose the consensus methodology. That was a great process. We had about 32 panelists that worked on that throughout the summer.
[00:05:28.490] - Kerri Machut MD
We went through three rounds We've been voting during that process, and we've analyzed our data, and we're putting the final touches on our manuscript this week, actually, and that will be out here, hopefully soon.
[00:05:41.550] - Daphna Yasova Barbeau MD
I love that. Thank you so much for the background. Before we really get into the framing statements and introducing the recommendations as they stand, I'm hoping you can tell me a little bit, are we the only people facing this problem? Why neonatal just compared to maybe some of the other pediatric subspecialists?
[00:06:02.310] - Kerri Machut MD
I mean, they think that in general, overwork in across medicine is not... We're not the only ones, right? I mean, you see the headlines even in lay press and social media that physicians are for that, physicians are working hard, the EMR that was designed to help us, and oftentimes it's causing more work burdens and various other things. But when you look at pediatric subspecialties, neonatology is actually one of the fields that has the highest total clinical work per year. Our colleagues in emergency medicine and pediatrics and adult also have, for many years, had much more of a cap on their work hours that have kept their clinical work hours in better balance. Even our critical care colleagues, I think that their models were to structure differently and have not grown in better pace in alignment with what their clinical needs are versus neonatology has been not maybe quite as on top of things because, again, so much of our workload was home call in the early days and where residents really provided a lot of in-house coverage. As I think we've all seen, the evolution of residency training and workload that has also shifted. There's now more left for the attending physicians to care for.
[00:07:23.600] - Kerri Machut MD
The caps haven't really kept up with that.
[00:07:27.810] - Daphna Yasova Barbeau MD
Malinka, I think you're going help us understand this problem a little bit better by providing us the overarching framing statements that introduced the recommendations.
[00:07:40.450] - Milenka Cuevas Guaman MD
Thank you, Daphna. Always happy to be here. One of the One of the things that we want to remind the audience and also remind ourselves is that it's not the five of us that decided to come up with these recommendations and put it through. Is we done some studies, like Keri mentioned, we did a survey of both chairman of Department of Pediatrics, leaders in what we call private practice with the division chiefs. With that, we were able to come up with some of the recommendations at the same token. We also did a survey, an informal survey of what we would call day-to-day neonatologists and the representation of, according to what the section calls, right, TECAN Early career neonatologist, mid-career neonatologists, all of them are represented. All of these was helpful to get these recommendations in paper, and then we put it through the Delphi method to go through, find out the recommendations. All of these recommendations, one important point is, they might not apply every single one of them to you, to your center, and that's okay. That's not what this was meant for, but it was meant to try to help as many neonatologists as possible. If you look at these recommendations, what are we trying to make sure?
[00:09:10.910] - Milenka Cuevas Guaman MD
What are our first three goals? Safe and optimal patient care patient always comes first. Then improve recruitment, protection, sustainability, and professional satisfaction of us neonatologists, all the neonatologists, and the neonatologists that are coming, so the neonatology go forth Finally, we want to maintain a scholarly advancement in the field. We don't want to forget about all of these things. What we want is to implement this in a systematic way, transparently, and equitable. You, at your local labor, are going to be able to define what that means. We're not trying to keep prescriptive methods. This is the way to do it. No. When the recommendations come, you need to look at your priorities because they're probably going to be different than mine or different than the next group. But one of the most important things is that everybody in your group should be able to look at this and come up well at your goals for the next couple of years. If you're already meeting them, great. When you're interviewing people, you can say, I already meet these recommendations, the majority of them. That could be a selling point for you, too. But the other the other important thing is that we're trying to talk very importantly of what a clinical FTE is.
[00:10:38.570] - Milenka Cuevas Guaman MD
We're trying to demonstrate that during this. When we list compensation, when we talk about compensation during these recommendations, we're talking about either reduction on clinical FTE, money, or both. That will depend on your local circumstances, too. I think that we need to also remember that some of these recommendations, as great as they look or you might want it and prioritize it, maybe it won't be applicable to your center right away. You have to take a long-term plan for this. They're not going to apply all the time because this is just a guideline. It's a guideline that hopefully will help everybody, one, discuss the same way about staffing. Because if I cannot compare what I do with what Daphna does with anybody that's in here or the next neonatologist, then how can we achieve a better staffing together? That's also part of what the recommendations are going to be talking about. I think that's a good preface to move on.
[00:11:49.310] - Daphna Yasova Barbeau MD
Yeah, I love that. I think it was so important how you introduced the goals because I think we underestimate how the two and three goals, really looking at neonatal professionals and how can we improve their longevity, reduce burnout, and allowing this time for ongoing scholarly work really is what holds up the number one goal, which is providing optimal care for patients that is safe and equitable, which we know that over time, our care has become less safe and less equitable. How do you think that people might be able to use the recommendations then to talk in their groups, but also maybe at the administrative level in the, say, the C-suite, addressing these needs with those people who may not spend as much time in the clinical realm as we do?
[00:12:39.800] - Milenka Cuevas Guaman MD
I think you're jumping ahead to our next bad law, but it's a good thing. It's easy to put out these recommendations. I mean, it wasn't easy. It was supposed to.
[00:12:51.760] - Daphna Yasova Barbeau MD
It doesn't sound easy.
[00:12:53.390] - Milenka Cuevas Guaman MD
But the recommendations go there. Then so how you apply it, how you do the advocacy and how you apply After we move this manuscript forward, we're going to also have a toolkit. The toolkit is going to try to help out, like you said, our bosses, meaning the pediatric chairmen, the division chiefs, or the leaders of practice, to try to have some idea on how to move this forward. But we also are going to have a part of the toolkit is going to be how every neonatologist can start these conversations as your interview for other jobs, as you're talking in your practice. The most important thing, the most important thing I think is, able to talk about it without fear of repercussion and without everybody thinking, Oh, neonatologists are just lazy. I think that's the most important point that we're going to We're going to start with, and that's how you're going to move this forward. Because I think when you get to read the recommendations or know more about the recommendations, some of them might seem obvious, but they're there because in some places, they are not. They're not common sense. I think the most important thing is going to be less discussed, and these recommendations might help some places more than others.
[00:14:27.740] - Milenka Cuevas Guaman MD
But still, I go back to we need to be able to talk about it and in the same language. Probably I'm revealing one of the first recommendations, but it's really your clinical time needs to be counted in hours per year. We know what is happening every single place in neonatology. I think one of the counterarguments is, well, I do it differently and it works excellent. Great. Now translate it to hours per year. Now we can really compare what you're doing, which is excellent, according to you, to what I'm doing with the rest of the world is doing. Then we'll have a common language. Until we get this common language, it's going to be very difficult to talk about the nuances and how we can even improve it and innovate it and change it when you're just stuck on, this is what I do and this is how I always been done it.
[00:15:22.710] - Daphna Yasova Barbeau MD
Yeah, that makes sense. Well, then I guess that's the perfect segue to just get into the rest of the recommendations. It sounds like you and Emily, will help us with this clinical FTE component.
[00:15:34.320] - Milenka Cuevas Guaman MD
I will say, Emily, go ahead and take it, and then I can go a little bit after.
[00:15:39.040] - Emily Miller MD
Yeah. I echo what everyone else has said. Thank you so much for the invitation to be here. We're clearly all very passionate about this work, both in our personal and our professional lives. I think that is one of the common themes that has come up, too, in addition to patient safety and advancing our scholarly work and for the health of our field is that this system also has to acknowledge the importance of flexibility. We heard from leaders, we heard from working neonatologists, that flexibility and staffing models has so many positive implications. Personal professional life, integration, physical and mental health, retention and recruitment have been mentioned. Some of the examples of flexibility that we heard about or that we've talked about are things like part-time or nocturnist models as an example, or just the option to restructure for conditions where the work environment might confer an increased risk. We know that night recall and fatigue really increase medical risk for folks who may be aging or may be pregnant or have other documented medical limitations. Also, being able to tailor your work arrangements for whatever professional track you're on. Someone who is focused on research may have a different type of work schedule that works better for them than someone in medical education or leadership or advocacy.
[00:17:12.280] - Emily Miller MD
Providing these flexible work arrangements really takes creative thinking. It takes intentional coproduction between leadership and practice members like we've talked about. Centers might need to test some of these solutions that are coming through the recommendations. They might to get feedback on how it's working and make iterative changes before arriving at a final solution. Some of the things that we've heard about alternative work arrangements or flexible work arrangements is that we recognize there may be some trade offs If a person is not able to, for example, work allocated night shifts because it's not safe for them, then maybe they need to make up their FTE with more day shifts, or maybe there's going to be differential compensation depending on what the center model looks like. We're not trying to assert that these flexible work models don't come with other associated trade offs. But choosing alternative work arrangements shouldn't have an adverse effect on the professional advancement process for one, and it shouldn't limit access to work supports or resources. Then the final aspect of flexible staffing is really how to cover leave and attrition. We know that there's always going to be leave. There's always going to be attrition within a group.
[00:18:34.920] - Emily Miller MD
You can plan for that unplanned aspect, so to speak. You can have a systematic approach that's prospectively determined and implemented. You might have one system, like a formalized Jeopardy or backup system for more urgent, unexpected brief periods of leave. But I think we all learned through COVID that a group text isn't really a system that works or is sustainable. Then for longer periods of leave or for attrition, maybe this is hiring extra FTE coverage. Maybe you're compensating existing practice members. You're recognizing that they're going above and beyond, and that work in that time should be compensated. Or maybe you're using locums. When we talk about flexibility, we talk a lot about these universal truths, where a This flexible model is going to look different for everyone. We recognize everyone's group size is different, patient population is different, how many locations we're covering is different. But there are ways to build this flexible model so that we can achieve the safety be the personal professional life integration, all these things that help us recruit and retain and have a really healthy workforce.
[00:19:53.170] - Daphna Yasova Barbeau MD
I love that. I love this idea. You've really highlighted the variety of pressure points that we're really feeling in the NHL. I mean, especially that the last minute scramble to find coverage is a huge problem. We all know that some people in the group pick up more emergency shifts than others for a variety of reasons. Either they feel the peer pressure or they have the availability to do that. In our group, I'm part-time, so I've got more opportunities to pick up extra shifts. Sometimes that burden does fall on me. I definitely can see how that outlining a plan for that would reduce stress across the board. I really like what you talked about and how making accommodations for one professional on your team doesn't mean that everybody else on the team has to suffer. There are so many different types of people that go into neonatology, different workforce goals in neonatology that probably each group can find a solution that makes everybody happy. Can you speak a little bit to that? Some solutions you've seen or ways that groups are trying to balance these, I don't even want to call them specialized accommodations, but different preferences around scheduling.
[00:21:14.500] - Emily Miller MD
Malinka, do you want to take that one or you want me to take that one?
[00:21:17.170] - Milenka Cuevas Guaman MD
Sorry, go ahead.
[00:21:19.590] - Emily Miller MD
There are so many different types of shifts in neonatology. We've talked about it as a pain point, but it also can be to our advantage. Perhaps you are a person who really likes to work during the day, and that's where your time is really going to be spent. Then your colleague who maybe is trying to get kids off on the bus stop or have sports and extracurriculars or things where maybe a nighttime shift is better for them or a weekend shift is better for Everybody in their personal lives has different family structures, celebrates different holidays. Maybe you're a person who really celebrates Christmas and you're willing to work New Year's or Thanksgiving and vice versa. I think having the transparent and open conversations where you're able to say, these are my pain points, and this is what would work for me, helps your colleagues and helps us all have this goal-oriented conversation around, Oh, you like to work that way. That actually works great because I don't like to work that way. I like to work this other way. This is better for me. I think, too, we have to recognize that just like the field is changing, our patient population is changing, and the system may need different things at different times, so are we.
[00:22:49.860] - Emily Miller MD
As we work and we go through different life stages in our professional career and our personal lives, the solution that's working now is maybe what's going to be working in five years or 10 years, and we have to also be able to revisit these. I think having, again, that common language of what does it mean to work in FTE? What hours are we striving for? Or how are we making sure we're equitably sharing the workload allows us to fit all of these puzzle pieces together in really unique and creative ways that work for everybody.
[00:23:26.230] - Milenka Cuevas Guaman MD
Thank you.
[00:23:28.610] - Kerri Machut MD
Well, could I add one thing to Well, your question also to build on what Emily was saying. We do know that there are actually a lot of centers and different groups out there that have found great solutions that work for them. It might not be everything is perfect in their staffing, but maybe they've got a great Jeopardy model, or maybe they've got a great weekend coverage model, or how they assign clinical applications. Part of the extension of this work, as Malinka was mentioning, is the toolkit. And so in that, there will be a lot of actually concrete examples for centers to borrow from each other in a repository of your information. Then I think the other piece that is going to be really important for individual centers is they're making a change, is some needs assessment. So what are your pain points? We'll have some example needs assessments in there so centers can survey their groups because maybe their group is actually really happy with how their weekends are, but they don't like their holiday coverage or vice versa or some other aspect. That will all be forthcoming also.
[00:24:22.550] - Daphna Yasova Barbeau MD
Very excited. Very much looking forward to that. I think everybody, I like that idea of a needs assessment. Really, what are the needs of your specific workforce? Link, I think you are going to finish up for us this.
[00:24:39.720] - Milenka Cuevas Guaman MD
There are lots of recommendations, so I'm going to give you a big overview. It definitely starts with, let's talk about the same language in hours per year. Then what should count into the hours per year? They're obvious. I mean, you are there, you're doing the work, but weekends should count, nights should count. When I talk, we know that we're talking really about the same hours per year, and it's not just your day time. We're talking about everything. Also, we want to make sure that everybody understand that handouts are important. Handouts should count, documentation should count. Try to think about all of those things that should count as clinical time. The same thing, if you are a center that takes a call from home, then it measure it. You all as a center, as a group need to decide, is it really being at the patient, being on call in the hospital is the same value as being on call from home? We don't want to assume. Maybe it is, maybe it's worse. They make the difference and try to look for those differences as your group. It's the same COVID at level 2, that COVID Level 4 is the same covering a level 2 that covering a level 4, is the same covering the primary hospital are covering 10 other satellite hospitals.
[00:26:07.170] - Milenka Cuevas Guaman MD
Whatever it beats into your group, try to look at those hours in detail and make sure that One hour, it's equivalent to another hour. Are you more of a teaching service? Are you more of a APP's nurse practitioner service? Are you a very acute center? You have three, four ECMOs plus a delivery center, and you're covering the delivery room plus you're covering the NICU with how many patients you're covering, how many other staff is below you that is going to help you. Only you are going to know these things. We cannot be prescripted and say this many number of kids, this many number of level 4, level 3, because even in level 4, level 3, level 2, they add a lot of differences. It helps us have a common language, but you need to also define your own language. What is that hour that I'm talking about for me and this level 4, for me and this level 2? If you're the one that actually prefer taking night call because you actually get better sleep at home, well, then where does that go? Where is the difference? The other thing is that we are introducing a lobby that comes from other working groups, sorry, other industries.
[00:27:26.360] - Milenka Cuevas Guaman MD
Also, part from us is that Some work, night work, that's usually called hazard work. It disturbs your sleep, it disturbs your health as a person. How long are you supposed to be up taking care of patients comes into question. Are we supposed to be the last one standings or actually we should have something scheduling a What about how many hours should be there. If that's a level 4, that's a level 3, that's a level 2, maybe it varies. But you need to look at your own center and say, How many hours I'm going to be here and how is my head? How is that impairing my head? It's not about, Oh, let's think about your driving home. I will give you an Uber. No, it's not. It's about the patient. Am I going to be the best as my hour one, as my hour 30, and my hour 24, my hour 16? I think we all come up with that we should try to minimize less than 24 hours. Is that going to impact how you do your staffing? It probably will, but try to see how it will, staffing How it's going to change.
[00:28:47.650] - Milenka Cuevas Guaman MD
I think we need to try to consider ahead of time when you're making the staffing, new serving lines. Am I asking the person that runs to the delivery room to also Do you take care of the same amount of kids that the other team is taking, but it doesn't have to run to the delivery room? Or your team is so acute, and on top of that, you have two EJMOS. Is that the right staffing, or do we need to create a different service line? In your group, you're going to decide what different service line is depending on your needs. Do I have so many fetal consults that I need to have another provider to do those fetal center consults instead of the one that's taking care of patients. Because how you split your mind, who are you going to prioritize? Running to the unit because something has happened on the unit or staying with a family while you're doing your fetal Center Consult or whatever other consult you are doing, because we know in neonatology, I think that's also something unique. We are, not starting, but we are continuing to sopper specialize. There's some ECHO, BPD, all of these things, line placements with ultrasound.
[00:30:06.280] - Milenka Cuevas Guaman MD
And so all of these people, how can we help them? How can we help all of these people that are giving their extra time? I'm helping everybody Because they're probably helping everybody in the unit. But how can we talk about that? How we talk about service lines? How do we talk about how many hours does that work equivalent to me covering the level 4, to me covering the delivery room? I think that's the most important thing about the clinical FTE and what we're trying to talk about, the clinical hours worked.
[00:30:37.530] - Daphna Yasova Barbeau MD
I like that. I really can appreciate what you guys have done, especially, like you said, looking at the other industries where this has been well studied. It's been ignored in medicine because we would have had to change what we were doing decades ago to really face how the night hours and duty hours and pro longed shifts affect patient care. I think it was easier for us to ignore it than to say, there are so many stakeholders in medicine now, end users in medicine. But really, the most important end user is the patient. I love how these recommendations are really focused on how do we keep the patient as safe as possible, given the evidence we have around shift schedule. I really appreciate the work that went into that. Thank you, Malinka. Now we're going to shift, it sounds like, to some of these non-clinical recommendations. What does scholarly work look like, administrative work look like? Christine, I think, will be telling us a little bit more about that.
[00:31:47.610] - Christine Bishop MD
Yeah. Thanks, Daphna. To your point, medicine has a work model that most other industries don't.
[00:31:56.960] - Daphna Yasova Barbeau MD
To tolerate this, the patient.
[00:32:00.610] - Emily Miller MD
No, it's like from non-competent clauses to our work model.
[00:32:04.940] - Christine Bishop MD
When we're looking at how do we want to acknowledge that we need to talk about these things differently, and then how are we going to talk about them One thing that's really important we think to talk about is what is the other work that neonatologists do? Again, to reiterate when Malinka said, this isn't just our opinions. It's not just what we're talking about. It's groups of everyday neonatologists, groups of leader neonatologists that we've interviewed and then a group of experts in the field. It boils down to that the other work is important. It can look different depending on where you work, whether you're in an academic or a university-based practice versus a private practice or a corporate-based medicine practice. But the bottom line is most neonatologists will do other work. What the leaders have told us, and part of the discussion is that in an academic setting, there are definitely things that are rolled in. Usually, there's like an 80/20 or 85/15 split where your clinical FBE versus the academic FTE and things like teaching and Some of that other work is rolled into that. Other than that, there was a lot of inconsistency of what leaders thought and what people think should or shouldn't be compensated, in these whole lists of different things.
[00:33:27.790] - Christine Bishop MD
Every practice, it was so fascinating when people would talk about what compensated at their practices and what's not, and it was very different. One center had a compensated director of lactation, and we were like, That's amazing. Then other centers didn't provide time or FTE compensation for time or money compensation for unit directors of a NICU. Part of the conversation was standardizing some of the ways that we look at this. What are the positions that every single practice need to run, like a unit director. There's an importance of compensating the unit director because of the extra work. But it's also, they are responsible for the function of the unit, which in turn is responsible for the quality of the patient care in a lot of ways. It always circles back to that primary theme. I think that talking about in a consistent way, recognizing that there should be compensation that these are time or money for some of these positions. Then also what leaders have started to recognize is that the newer generations of neonatologists will neither be recruited nor retained unless these things are very clearly defined and then also compensated. The workforce is changing.
[00:34:50.570] - Christine Bishop MD
I think part of the reason why we're talking that was now is because if we don't change with it, then it's going to be problematic for neonatologists and our patients in the future. In a large system... Oh, go ahead, please.
[00:35:02.460] - Daphna Yasova Barbeau MD
Well, we're already seeing that in convincing trainees to go into pediatrics and then convincing pediatricians to go into neonatology. We're already seeing some of this fall out.
[00:35:14.330] - Christine Bishop MD
Yeah, Absolutely. I think that's what's important is how do we... I think the importance of this work, one of the most important things is how do we set our field up for success? Because you don't go into neonatology, necessary because you love the work hours.
[00:35:31.520] - Daphna Yasova Barbeau MD
Most of us do 24-hour shifts.
[00:35:35.530] - Christine Bishop MD
Some of us still do 32-36 hours shift. We do it because we love taking care of the patients, and we love the academics, and we love being part of that care model for babies. How do we make sure that this is sustainable for the future? In those discussions, funding always comes up. Funding is outside of the scope of our work, except to acknowledge and the really everybody acknowledges that probably funds flow and funding needs to change because to support the clinical areas that we're talking about and to support some of these other areas, some of that money that may be flowing away from neonatology divisions, probably needs to stay or flow back. Again, this is not our area. This is really some of the different leaders that have discussed this, because every time these things come up, how we're going to pay for it as part of it, which is why this will all take change. It may be hard, but it is something that needs to happen.
[00:36:37.890] - Daphna Yasova Barbeau MD
I'm sure people are listening and wondering, both in the clinical component and in this non-clinical basket. Have you guys made any formal recommendations about what an hour should look like or how many hours per year, things like that Yeah, I think that as far as sperm recommendations, I think we have to be really cognizant and thoughtful about that because I think everyone who's talked so far said there should be some universal truth, but it should also be modifiable at a practice level.
[00:37:18.310] - Christine Bishop MD
There is a group, the Swann Group is working on the numbers per year recommendation. That was an undertaking that we did not have as our duty. So hopefully that will be published at some point in the near future to provide guidance so that people can take that to your point earlier, take that to their C-suite and say, Hey, this is the recommendation. And then along with the guidelines that we're going to be publishing to help them further modify that work. Malinka, I saw you unmuted. If you want to speak to making some of the other recommendations.
[00:37:55.400] - Milenka Cuevas Guaman MD
More than giving you a specifics of what should be It's really you need to look at your own practice and making sure that not two people are making the stopping. Even go further to say, Can I If I was with you, Daphna, can I explain Daphna's hours? I should be able to explain Daphna's hours, just my hours. I should be able to explain why Daphna gets this and why I get this and have an idea what all that means for everybody. I may not know the little details, but I should be able to explain why my partner is doing it, what my partner in the community is doing it, depending on your practice, how this looks like. I think that's the most important thing that we all look at it together and decide. We call it night hazard because it is recognized to be hazard. But maybe for you, the weekend is hazard. We know that usually they're on the terrible hours because it's the weekend, maybe you want to spend more time. But like we say, you are also changing through your career, and maybe you don't have any more responsibilities on the weekends or actually you prefer to do that, and that way you can have more work during the week time to have meetings or whatever it is that your interest, academic interest is.
[00:39:22.650] - Milenka Cuevas Guaman MD
Another point, I think, is the academic interests are dead, even if you're not an academic institution. Those lines have learned a long time ago. I mean, you would prove of that, right? But I think it's very important to recognize that, too. Oh, the private practice does this and we do this. No, the reason that any on. Some language that we're going to use here as blocks that might be more of an academic practice way of talking that a private practice might do. But still, there are going to be recommendations here that are definitely going to apply to you if you read through them. Also, one other thing that we're trying to give in during these recommendations is we're giving a content and clarification. If it sees that I'm changing something now that I'm talking about just the weekends, no, go back to the first one. You still need to count in hours per year. Now we're concentrating the weekends, but still go back to that and think about this recommendations this way. I think that's the most important thing.
[00:40:34.620] - Daphna Yasova Barbeau MD
Yeah, I appreciate that. Thank you for those clarifications. I actually think even when people can get on board with the clinical FTEs, it is this basket of all of the things all of us do, even if we're 100% clinical, that we do all of the extra administrative work, teaching work. How does clinical work like consults or clinical work like a follow-up clinic count compared to those units, to those hours in the unit. Christina, I wonder, how are you asking people to look at that, to expand that perspective so that they can take into account all the amazing things that everybody they work with does?
[00:41:23.200] â Christine Bishop MD
That is a very complex question because every group is so different. I think a primary factor is separating the clinical from the non-clinical and recognizing that an hour of clinical work is an hour of clinical work. An hour spent in clinic should not be valued as 50% of an hour necessarily spent on an ICU as far as time-wise goals, but a practice may beam it differently. As far as a clinic day might be 5 hours and an ICU day may be 8 to 10 hours. I think recognizing that, piling on these extras, being in the clinic, being prenatal consult, being the follow-up clinic, that shouldn't necessarily be FENAS in addition to the clinical FTE. It should be wrapped into the FTE. It should all be considered. Then saying, yes, we acknowledge that there are other non-clinical things that are important. Qi is imperative for a NICU to function and to provide good patient care. Unit directorship. There are a lot of different things that are imperative to the function and to patient care. Then also within academics and things like that. Asking people to recognize that and then to compensate with time or money. I mean, that's the bottom line. Interestingly, when we asked leaders, there were some disagreements. Some people thought it should be time. Some people thought it should be money. It should be money. Some people thought the employee, the neonatologist, should be able to pick whether it was time or money or it should be both. There's a lot of opinion. But the universal truth here is that work needs to be compensated and we need to look at these things more closely. We're not consistently just piling on more and more and more and expecting neonatologist to take it. We're in-house call now instead of home call. We're just going to take it and not increase pay or not decrease other time. Oh, we lost three people in our group, so now we're just going to work more 32-hour shifts. That fluidity isn't really going to be acceptable anymore. I don't think with future generations of neonatologist They think they're going to want more fixed models and more transparency and more clear expectations. I think that's what it really boils down to. We're not trying to be perspective. We're trying to say, these are the truths that you need to or that we're recommending and the guidelines are going to speak to. We, the royal we, of all the people that participated is it not just the five of us, but we keep saying that it's not just we who are saying this.
[00:44:11.940] - Daphna Yasova Barbeau MD
Yeah, no, I think that's wonderful. I think there are so Two industries where people are expected to work for free. We could probably count them on one hand, and medicine is at the top of the list. So thank you guys for reviewing the recommendations. And Cristiana, you are going to tell us a little bit about what comes next. I heard a little bit about the toolkit. Maybe you can outline that a little bit better for us. Then what does the future look like?
[00:44:39.890] - Christiane Dammann MD
Thank you, Daphna. That's the question. As you can imagine, finding the consensus and coming up with the recommendation was a huge, huge step. We thought just sitting on it is not really helping because we have to translate that and help translate that into our life in order to make sure that there are changes coming up. As mentioned before, we are working on a toolkit to support and optimize staffing practice in neonatology. The target audience for that will be institutional leaders to assess and make needed improvements to workforce staffing in their group, in their institution. But it also should help individual physicians to learn about optimal staffing practice and advocate for change, not only if you are looking for a new position as an early career or a changing position as a mid career. It also should be able to be used while you're working in a group to constantly look into improvements and needs for improvement. This has been mentioned multiple times. It is really the principle we are looking at is to really create transparency so that everybody knows what is going on. If you hunt for a new job or if you are in a group, you should know what your annual allocations for certain things are, not only the hours, but what you need to do.
[00:46:40.180] - Christiane Dammann MD
Then it should also really focus on equity and be similar for all the groups in the hospital. It should also be adaptable so that it meets evolving needs over time, generational distinctions, and other expected situations which we all know can happen. But it should also, as mentioned before, engage all the physician stakeholders in the group, so it can be democratic In order to really translate that into life, we wanted to give the leaders talking points to really advocate with their administration, how to increase FTEs, how to really deal with hiring. When you create a new service line, what needs to be aligned in your center, comparing your subspecialties you are serving or you're working with. But also for the individual, the stakeholder who's working in the group, so that they can ask questions They also, when they seek a new job, they have ideas what to look for and how to negotiate, so they can use it as a negotiating tool. There is a lot to be done, as you can imagine, in addition to the work which already has been done. I hope that we will get younger physician, early career, even trainees involved, so that we can really look into what is needed at that stage, but also have mid-careers and elderly people involved so that we can really create the toolkit for everyone there is out there in neonatology.
[00:48:46.930] - Daphna Yasova Barbeau MD
Can you tell us a little bit about how people will be able to access this help so they can take it back to their units?
[00:48:54.440] - Christiane Dammann MD
We have created a toolkit for gender equity, and we have published on that, so we will definitely publish the toolkit, but it's also accessible, hopefully, on the long run through our sections community site.
[00:49:15.840] - Daphna Yasova Barbeau MD
Love that. I know that you guys have done a lot of QI work, so doing the work, studying the work, and then seeing how that changes over time. What does studying the recommendations look As you know, QI is not only needed for our clinical duties.
[00:49:38.860] - Christiane Dammann MD
It also needs to be done in order to really build in all the changes we are living through in our life, in our society. So QI work in constantly looking into the changes and needs for updates, and also looking into how has change, rebuild our workforce. So it is needed, and hopefully we'll be able to have not only us, but other people continue to look into and get funding for that work in order to really continuously work on our workforce and the well-being with the Our utmost all goal to serve our patient population in a safe and secure way.
[00:50:36.260] - Daphna Yasova Barbeau MD
I love that. I see lots of people shaking their heads, nodding, smiling. I know we're getting to the end of our time together. Did anybody have other closing thoughts to echo what Christianne is leaving us with?
[00:50:50.490] - Milenka Cuevas Guaman MD
I think I have only one. This is going to take years. It's not going to be the recommendations are up and tomorrow, everything's going to change because on how we work and where we are. I would call for younger neonatologists or future neonatologists to continue to work on this. Most importantly, don't be afraid to speak up. I think the only way that we're going to move this forward is actually with new ideas. It's not just restructuring the work. This is what I'm doing. To complete recommendation number three, I'm just going to restructure this part. No, I don't think necessarily, momentarily for the first year, maybe that will work or the second year. But that moving forward is not probably going to work. I think we as neonatologists and the future neonatologist, we need to really be innovative and stop going back to, this is the way we done it all the time. I survived. I'm glad you survived, but that's what we want. That's the nature we're living. I think that's where it comes, where the future is going. It's really only out to us.
[00:52:14.970] - Daphna Yasova Barbeau MD
Okay. Well, I am so grateful for the work that you're doing. I know that this is a hot button issue in our community. People are feeling a need for it. I think if you've been listening along and you say, I don't think this is a problem in my unit, then maybe you haven't paying close enough That attention is what I will say. I hope that everybody will heed your advice, will go back and reevaluate what they are doing and what they plan to do for the future, all with the guidance of your new recommendations and your toolkit, which we're very much looking forward to seeing and using. Thank you all for all of your hard work and dedication in helping secure the health and the well-being of future neonatologist and all babies that we care for. Thank you for your time.
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