#018 - Dr. Diana Montoya-Williams - Health equity research in neonatology

Dr. Diana Montoya-Williams is an attending neonatologist in the division of Neonatology at Children’s Hospital of Philadelphia, a clinician scientist in CHOP’s PolicyLab and an assistant professor of Pediatrics in the University of Pennsylvania’s Perelman School of Medicine. She graduated from Harvard College with a degree in the History of Science and received her medical degree from Columbia University. Subsequently, she completed her residency in Pediatrics and her fellowship in Neonatology at the University of Florida. She conducts research on the drivers of racial and ethnic inequities in infant health outcomes. Her recent work has also explored structural and individual factors that confer resilience to poor birth and infant health outcomes among populations vulnerable to discrimination. Dr. Montoya-Williams has a special interest in immigration policies as political determinants of Latinx health outcomes. As a member of CHOP PolicyLab’s Health Equity team, she also engages in legislative and policy advocacy.

Dr. Montoya-Williams can be contacted by email: MONTOYAWID@chop.edu
or via twitter: @DrDianaMW

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As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd. Papers discussed in today's episode are listed and timestamped below.

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As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

Enjoy!

Transcript

Ben: 0:38

Hello, everybody. Welcome back to the podcast. Dr. Barbeau. On time, no. See, what do you been up to?

Daphna: 0:45

Since we last recorded not much, but

Ben: 0:48

I know we recorded the journal club like 1015 minutes ago.

Daphna: 0:53

But we have come to life,

Ben: 0:55

but we have to pretend like we haven't seen each other for a week so that you know, there's like this anticipation and all that stuff. So

Daphna: 1:01

well, I we have a lot of anticipation. We're very excited today.

Ben: 1:05

Yeah, this is this is an awesome episode. I'm looking forward to speaking to our guests. Do you want to introduce our guest today since you know her very well?

Daphna: 1:13

Yes, it would be my pleasure. So today we have Dr. Diana Montoya Williams, who's an attending neonatologist in the Division of neonatology at the Children's Hospital of Philadelphia. She's a clinical clinician, scientist and chops Policy Lab, and an assistant professor of pediatrics in the University of Pennsylvania, Perelman School of Medicine. Diana graduated from Harvard College with a degree in the history of science and received her medical degree from Columbia University. Subsequently, she completed her residency in pediatrics and her fellowship in neonatology at the University of Florida where I had the pleasure of getting to know her. She conducts research on the drivers of racial and ethnic inequities and infant health outcomes. Her most recent work has also explored structural and individual factors that confer resilience to poor birth and infant health outcomes among populations vulnerable to discrimination. Dr. Montoya Williams has a special interest in immigration policies as political determinants of Latinx health outcomes, and as a member of chop policy labs Health Equity Team, she also engages in legislative and policy advocacy. And then on a personal note, Diana's, admittedly one of my closest friends from residency and fellowship fellowship, she was my study, buddy, we were raising up our little babies together before she moved away for me. She's one of the most compassionate physicians I know. And so we are so excited to spend this time with you today. Diana, welcome. Thank you.

Unknown: 2:44

Thank you so much. That introduction was too much. But I really appreciate it. And I am so excited to

Daphna: 2:50

be here. Well, you know, there's a lot to unpack here, even in our, in our intro of you. And so we've got a lot of things to talk about. But maybe you can just tell us a little bit about kind of your academic journey, because your kind of area of interest has has changed a little bit since since fellowship. So tell us where you came from and where you're going?

Diana Montoya Williams: 3:17

Sure. I love telling my story. So thank you for the space in the platform. So I, as you mentioned, have been lots of different places. And originally I was born in Colombia. So I am bilingual bicultural, that the man, immigrant first generation and that really, more and more. As I develop my my profession and my professional career, I realize how much that has informed my journey and continues to inform the work that I do. So I was born in Colombia, and my parents immigrated to the US when I was quite young. I grew up here in the United States, this is where I was educated. This is where my life is and where I'm raising my children. And I had very early interests in sort of how society and social forces and history impact current and present day health. And you know, I started exploring that more from like a historical anthropologic basis in college. And then in medical school, I learned a little bit about health disparities, but just through mentorship, it didn't feel like a very formal part of my curriculum. And it was it was not quite the right fit. All those early experiences were were fruitful now, with the sort of the guise of like, looking back, but at the time, you know, it was it was it was just experiences that made me think like, maybe research is not for me. So when you met me, Daphna and I was becoming a pediatrician. I thought I was going to be I knew very early on, I was going to be a neonatologist, the NICU and the delivery room has always been my favorite place and hospital. It's to me the most exciting place with the highest of highs and the lowest of lows and it makes me want to continue to be in medicine for the rest of my life. So neonatal medicine has always been my my North Star, but it was really fun. fellowship that I started coming back to this idea of social determinants of health, and how what happens outside hospitals really impacts what happens within hospitals. And I started re engaging with this issue of health disparities research, and how health disparities have been incredibly pervasive and incredibly persistent among racial and ethnic minoritized communities in the United States in particular. And so initially, I started doing a lot of more epidemiologic work related to that and trying to look at datasets, both in medical records in birth certificates, and that's still some of what I do. But over time, as I graduated fellowship, and I started this faculty position here and have gotten a lot of on on the ground education from my colleagues, both in the community and in Policy Lab, I've started to really expand the work that I do beyond just epidemiologic, quantitative work and really started to explore a much much broader mixed approach to research that is really honed in on how do we create a great evidence base for policy that improves individual health and population level health outcomes, particularly for communities that have been disenfranchised, discriminated again and minoritized, both structurally and individually. Like, as you mentioned, my in the last year, year and a half, really, two years, I've realized that my passion and my identity, my personal identity, has made it so that my focus in studying both structural and individual racism and how that impacts health can really hone in and where I can really contribute as to how structural and interpersonal racism plays out in Latina immigrant communities. Specifically, because I'm a neonatologist, and interested in the perinatal field, how it impacts pregnancy and birth outcomes and infant health in the first year of life. So I've started with some early research experiences that made me think I'm never going to be a researcher and fellowship, I was like, Okay, maybe I'll be a researcher, because this is really interesting. And, you know, sitting in that office, we used to share, like, I started writing papers that made me want to read another paper. And that's how I knew like, okay, maybe I do want to be a researcher, and then coming to this to this faculty position, and meeting a lot of like minded individuals and parallel minded individuals has made me realize, where I can pull all those forces and make my individual contribution and science. That's very

Ben: 7:25

interesting, right? Because I mean, through our training, we get this pressure of like, you got to do research together, you got to publish, you got to do research, and then on what is completely secondary. And it turns out, I think your story is interesting, because it's not about doing research. It's about finding an area that sparks your interest. And then your curiosity will take the lead, you know, and make you ask the question and try to look for the answers. So I think it's a very, it's a very interesting path where you sort of move away from research, because research seems very dry, but then the topic of interest comes around, and now you want to do research. It's just the way it should be right.

Unknown: 8:03

100%. And frankly, I think like when it's not like that, that's really what leads to so much academic burnout, right? Like, if you if you embark on some of these research projects, where what's driving you is not just to

Ben: 8:15

get a paper out?

Unknown: 8:16

Yes. And maybe even like, I mean, I can, we can like this is like a tangent, but maybe that's what leads to lots of papers that maybe have less, less value. But I think, you know, there's something to be said for researchers that really connect everything that they bring to the table individually and personally and professionally to the work that they're doing to keep us in science, because it's not for the faint of heart.

Daphna: 8:41

I'll tell you that. I've

Unknown: 8:42

learned that in three years.

Daphna: 8:44

Yeah, you've been been really laying the groundwork, these these last few years, and were recently awarded a Kay grant. Tell us a little bit about that, and what that looks like for you.

Unknown: 9:00

Sure, thank you. Yes, that was definitely a big milestone. And one of the most complex learning experiences of my life thus far is how start and label it. So definitely when I was hired, at CHOP in the position that I was hired, was with the expectation that I would be a physician scientist, and that my time would be very heavily invested in research, in addition to my clinical duties, but so Chuck has a very interesting pathway for early career physician scientists where they and this is really pen and chocolate, not just talk but like where they protect your time even before you have external extramural national funding with the hopes that within a short period of time, you will have producing papers and applied to grants to protect your time yourself and sort of launch yourself into an independent pathway. So I was hired under that sort of framework and expectation and, and that was very helpful because early even as a you know, transition for fellowship to attending, I had a lot of protected time to develop my research portfolio as a faculty member. And so what that led to when I first arrived here with the help of my mentor, Dr. Scott Lord, to whom I'm incredibly indebted, and another incredible mentor, Dr. Heather Burris, who I continued to do work with these two mentor incredible mentors here at CHOP is developed a lot of projects using existing data to really launch myself because especially as an early career scientists, the best thing that you can do is to try to learn skills and start to write as to publish and start to establish a track record of success in connecting in journal publications and grant funding. using existing data. It's very hard as an unfunded early career researcher to start with formal prospective data collection. So I was very lucky to be in this environment, where my mentors had access to these large datasets that had birth certificate data, or I use a lot, I did a lot of projects with data set called the adolescent to adult health cohort, which was this incredibly large longitudinal survey repeated measures survey of kids who were in middle and high school, and then they got interviewed over many waves over almost 20 years to see how their health and their social determinants of health and their neighborhood changed and impacted their health across time. And I was able to use that cohort to ask some initial questions about what resilience might look like among women who were children who had transitioned into adulthood, and were having babies. And what that how that those resilience factors and those stress factors might be impacting their birth outcomes, mainly their low birth weight and their premature risk. And so those initial projects made me really interested in these in this interplay between birthing person's, like life factors that might be really stressful, either acutely or in a chronic way. And factors that may be traditionally labeled or captured on resilience surveys, or resilience, you know, items and protocols and things like that, that have been studied in primarily in the psychology literature. And whether that could help us understand both on an individual and a community level. Why is it that someone is burned outcomes differ over time and across generations, and by these, you know, socially constructed categories of race. And so that really launched the initiative, the research questions that I then wrote my K 23. Grant to the National Institutes for Child Health and Development, where, like you mentioned it, I was just notified a few months ago of support for the next five years to really try to understand what stress will the cute childhood chronic stress looks like for birding Park for the people, and how that might change during pregnancy. Because as you and I both know, pregnancy is not a static experience. There's a lot that's changing, physically, biologically and emotionally during pregnancy and afterwards, and how that kind of trajectory of stress and resilience might impact road outcomes and birth outcome disparities and even disparities that we know contributes to infant mortality in the first year of life, namely breastfeeding. So that's really what my K 23 is about. To be able to start to establish sort of longitudinal data about how these factors may or may not change during pregnancy.

Daphna: 13:18

And I want to get to that, but the I'm, I know you and I know your kind of life story. And so for people who don't know, at the same time, while you're kind of developing this love for pregnancy and pregnancy related health, you're having your own little babies, right, you're attending, you're a mom, and you're really launching this academic career. And so I can only imagine how much closer you felt to the work with all that happening at the same time.

Unknown: 13:51

Thank you for pointing that out. And for naming that, because it absolutely is part of my journey. You know, being a mother, as I embarked on this type of research, I had my first child as you know, during fellowship, and then my second baby, I literally submitted my first application to the NICU HD and three days later was infused. So it was a very temporarily tight relationship there. And so it definitely it definitely there's no more human to like doctors and scientists, we're all human. So it's definitely like on my was on my mind, like thinking about stress and how stress can be bad for pregnancies while being pregnant and wild and trying to breastfeed has definitely impacted and really filled my cup for this work. Because on a firsthand level, I know how important this can be and why it's a it's why it's necessary for science to better understand support living through these pathways.

Ben: 14:46

I think this is this is a very interesting topic that you that you embarked on. And it's an it's a very contemporary one as well. I mean, we obviously are living in an era where we're trying to bridge As much as possible those gaps in disparities. What I wanted to ask you was really related to the fact that you're a neonatologist, and you're talking about social determinants of health. And I felt every time I've read on this topic, it does feel a little bit like global warming. It's like, well, you know, like, I tried to do the best I can at home, but like, what else do you want me to do? You know, it's so so the mother are exposed to various stressors during their pregnancy because of their societal context. But, and I'm not disagreeing with the findings. I'm just saying, from me little neonatologist in the ICU, what can I do? And where, where is my work going to contribute to minimizing the social determinants of health? And I think this is why we're so happy that you're on so that you can maybe talk more to that.

Unknown: 15:50

Oh, yeah. And I, I would also, I would start by saying, You're not a little neonatologist, you are you guys are becoming such a force in neonatology, especially in neonatal education. So don't undersell yourself and your voice. But I'm glad you asked that question, because that's definitely something that I hear and sometimes NFN being 100% honest, that I feel and that I need to always reassess on a personal level as I do this work is how can my career and the work that I do in the words that I write on a computer like transcend paywall protected journal, right, that's not the goal of this work is to just live in an ivory tower literally and behind paywalls. That I think what I have started to learn, and this is definitely a journey. So it's not like I have all the answers. But what I've started to learn, especially from a lot of my colleagues, and predecessors, especially, you know, scholars of color, that have been doing this work for a long time with a lot less recognition is that there are definitely lots of strategies that you can, you know, engage with, regardless of the hat that you wear within academia, medicine, hospital, clinical work, to start to be the kind of, you know, I use this metaphor, with Daphna recently the trickle of water against the stone of health inequity in our society and really start to try to make change within our own individual context. And I really, I really do have to, like take a minute to like, acknowledge the education I personally have received, both directly but also indirectly through places and spaces like Twitter, from some really prominent race scholars, both within and outside of medicine. You know, people like Dr. Camera, Phyllis Jones has taught me a lot, you know, she probably doesn't know who I am about the differences between structural

Daphna: 17:38

yet she does.

Unknown: 17:40

Structural and interpersonal racism and people like Dr. Rhea Boyd, an amazing pediatrician has taught me about like, when if I'm sitting racial disparities, what am I actually studying and what is racial disparities mean? Or what is race as a variable in my research? So I'm gonna talk a little bit about how you can do that as a researcher. And then there's people who, like Dr. Dorothy Roberts, she's actually she's a lawyer, I keep wanting to, you know, promote her to switch her. She's a lawyer.

Ben: 18:07

She's a Juris. She's Juris Doctor, I

Unknown: 18:09

guess, right? Yes, Juris Doctor Roberts, but she ever listens to this. But Dr. Roberts has taught me a lot about the socio political history and how that impacts current ongoing racial conversations about health. And so a lot of what I'm what I can talk to you about in terms of concrete strategies, is really due to like the talking, the speeches, the lectures, the writing of some of these people that came before me. But that's a whole big segue to say that I do think there's a lot that neonatologist can do, no matter what happened were to either contribute to knowledge base, aimed at dismantling health inequities within neonatal contexts, but also to try to change experiences within individual health systems and within individual interact clinical interactions and experiences for their patients. And, you know, I love talking about this. So we can talk about this recipe if you want. But to me, no matter what hat you wear, whether it's educator, Qi specialist, clinician, researcher, Administrator, there's things that we can do in our day to day lives professionally, and even personally, to really start to tackle some of these issues.

Daphna: 19:22

What I think you already highlighted is that we can't do it alone, right? Like you need this collaboration with people, both in and outside of medicine, physicians and other scientists to really to do the work and it sounds like you've had a lot of mentorship both in and out of medicine.

Unknown: 19:44

Yeah, absolutely. Absolutely. Like I'll give an example. For instance, there is a project I'm working on right now. That is led by one of my incredible mentees and now colleagues Dr. Michelle Marie Pena. She's a natalensis brand new nematology sera Cha, that I've been fortunate enough to mentor and call a friend. And she has been, she's really becoming a leader in terms of equity focused quality improvement work within the NICU. And she finds out, I'll explain some of her project and how that totally gets at what you're saying in terms of collaborative work, and how that can really move things forward. So she's doing this project where we're aiming to try to increase, not just breastfeeding initiation rates among patient population at our hospital, but also breastfeeding at discharge, to outcomes that we know have incredible racial ethnic disparities, and which are intimately tied to risks of infant mortality in the first year of life. And so, our our hospital system here, our birthing hospital, or delivery hospital is in West Philadelphia, which is primarily predominantly African American. And so this work that she's doing is transcending Qi work that I've ever seen or been engaged in. And the way that she's doing it is she has created this incredible team that has tried to tackle different parts of how we can potentially improve breastfeeding rates among specifically directed African American reading parents. And so we have, she has a subcommittee of people from nursing and physician backgrounds who are looking at policies related to breastfeeding women, she has a completely separate group of people who are doing a qualitative interview study of black moms, blackballing people, sorry, to see where they get their information about breastfeeding from and how we can intervene on that. And in that subgroup, which is the one that I'm a part of, we have lactation consultants from the community, not even from the hospital system. We have lactation consultants, we have doulas who come from the community, in addition to all of the people that work on those early breastfeeding days within the hospital system. So we have this like constant communication between both healthcare providers within a healthcare system, healthcare providers in a community setting, who are working, and then we are we be pilot tests and have been interviewing, you know, black moms about these issues. And so to me, that is like a classic example of a how hard this work is and how much time and money needs to be invested in it to be done right, because we pay she pays all those people for their time. These doulas, these lactation consultants, these that are out in the community are formal consultants, their research partners, but they're paid. And that's really important for this type of work. We've done this work on paid for far too long. But it's teaching us about how when we develop an interview guide, and we think we're asking the right question in the most rigorous of way, like how those words might be interpreted, and really turning off our participants and not getting the data we think we're getting, which then turns into a project a paper that maybe isn't having the impact we think it's having, and disparities continue. So it's been a really interesting project to see how much bidirectional knowledge sharing has to happen when some when you engage in equity work like this.

Ben: 23:09

It's interesting, right? I mean, in from a methodological standpoint, I wanted to see what your thoughts were on the concept of looking at data to sort of uncover disparities, and how numbers can lie all the time. So for example, you could look at survival rates, and you would say, well, African American females survive more. Does that mean that the disparity is not they're completely false. But if you just let the numbers, do the talking, you easily can get fooled. And so I'm curious to see what your thoughts are on if the approach is different at this time in the field of health disparity research. And if you feel like there's going to be a shift that has to come soon, especially as we're introducing artificial intelligence and large data sets, to assess for disparities in other many, maybe even sometimes more meaningful ways.

Unknown: 24:06

Thank you for that observation, I think you hit the nail on the head in terms of the the, the double edged sword of research and science is that you can produce conclusions but whether the conclusions are, are reflecting the truth, especially for for communities that are disenfranchised, is a really tough question and something that at the very, like, at the most fundamental level, we just have to continuously ask ourselves, so even asking that question is so fundamental, versus just assuming that your conclusions are valid. And to me, that's the beauty. And the hard part of science is that you could do a whole study and make some conclusions and have completely be humble about the fact that you may have come to the wrong conclusion, but to some more concretely answer your question. I think that in my opinion, like moving, moving needle on health inequities and towards health equity is going to really require much more. A much more concrete investment in mixed method research methodologies, and investment in how we bring these two types of data of two types more than two types of data together into really what what some of us call fourth generation, implementation and evaluation. So a lot of the work on disparities historically has been on naming disparities on doing what you're saying, like, like looking at numbers, and just documenting them. And especially when you when you hear and read from researchers within these communities of color. And using disenfranchised communities like there is enough data, both lived and on paper of inequities. And what we need to start to move forward is beyond just naming beyond, replicating beyond even just suggesting solutions is really like implementing and reiterate and iterate on solutions, and and strategies to work. So that's fourth generation health equity work is what we like to talk about it. And that's really to me, where the focus should be both on time and frankly, on funding and grants. I think the time has passed for just describing disparities, and it's time to really develop interventions, test them in one context, test them in another context, get people's feedback, look to see what happened before and after policies and law legislations on a population level, get people's context and their and their lived experience and bring this data together in a way so that we can get a better understanding of like, okay, this policy in this hospital had this impact. Perhaps if it's implemented in this other hospital in different geographic region, it might have a different impact. But we won't know until we iterate and test and evaluate right? And so to me, you need both of those data's and that's really the future of health equity work.

Ben: 26:50

That's, that's, that's, that's the potential problem is that, like, you're saying, we need iterations. And I feel like there's so much sometimes opposition that people will say, well, it didn't work. So like, while you're trying it again, and it's not the point. The point is that you have to sort of this trial and error is necessary. And that's an important thing for people to understand.

Unknown: 27:11

I know and it's and it's not foreign, right? Like, I recently listened to your podcast on steroids, right, and steroids for BPD, and survival. And as you can tell, like we are used to in science and medicine, testing and retesting different strategies with the same medication to see if like, you tweak it this way, or you do it this way, or do it in a different context, like whether it has the same effect of equity research, while some people have a tendency to see it as different. It's really not like, we have to apply similar research methodologies. Implementation Science is incredible for this, to test these strategies, because what we know about racial ethnic disparities is that one size does not fit all, like, and when you think you're having a population level impact, if you don't measure outcomes, granularly, you could be really missing not only stagnant disparities, but worsening disparities, which gets to your point, Ben, about what you were saying about numbers line like, right, I feel that comments so strongly, especially as a Latina health outcomes researcher, because Latino health outcomes. Research in this country has been, you know, definitely guided by this concept of the Latino paradox or like health outcomes paradox, which is, you know, even though it's, you know, communities, Latin X communities have had have similar risk factor profiles, as you know, our non Hispanic black African American communities in terms of access to care and quality of health care, they seem to have much better outcomes. And that for that may be true and has been true for certain subgroups of Latin X communities. But it's absolutely not true for all and it's such a heterogeneous group. And we have absolutely missed deep disparities amongst certain sectors of Latin X community, because of this belief that the Latin X epidemiologic paradox means Latinos are fine, and their outcomes are fine.

Ben: 29:00

And that's, that's where I think everybody should learn statistics much more than many of the other useless crap that we learned in school because it would allow us to see data in a much more robust way. Definitely to ask one more question.

Daphna: 29:12

You taking up all my time here?

Ben: 29:14

I'm sorry, I'm going for it. The The other question I had is, you're talking about redefining how we're looking at data, how we're conducting research and I feel like a lot of institutions are dedicating time and resources by hiring individuals who will take on this mantle, but on the other hand, how do we avoid the siloing of this work where Oh, she's the person doing the equity research. I don't have to worry about it. We got someone working on that when in truth, it's a rethinking of our approach to health care delivery. This is definitely an obstacle. I'm wondering how you envision the future where this this this philosophy will sort of seep through the entire department. The entire department of the hospital.

Unknown: 30:04

I mean, just exactly how you said we need to allow it and not just allow it, but actively foster it seeping into every fabric and every aspect of academic and non academic medicine. And so to me that what what that looks like is making health equity just as strong a pillar in medicine as we now consider quality, for instance, right? Like when you think about some landmark papers that think like everything we do in medicine, and science should be on a pillar of quality, how do we assess quality? How do we ensure that quality is being met, we should treat health equity the same way. And it's taking quality and making sure that everything that we do in medicine, whether it is a clinical practice, whether it is research, whether it is a change in practice, whether it's how we do outreach, is making sure that it's having the intended effect and not an unintended effect. And a lot of that comes down to measurement and how you start to measure this in whatever work that you do. So to me, to me, what that looks like is every quality improvement project that anyone undertakes in any ICU, really any clinical setting, but and we're talking about the NICU in any clinical setting should you know if if one of the initial steps is we should establish what our baseline, you know, variable looks like so that we can understand what we're trying to change. And through our PDSA cycles from people in Qi, we should be making sure that those baseline data points are stratified by categories that we know disparities exist, it's impossible to know whether you are affecting improving or worsening disparities if you're not measuring baseline data. So that's really one of the major major tenants of equity focus Qi is, if you're going to implement a breastfeeding QI project, you have to make sure you know what your baseline racial, ethnic, potentially other categories, like if we're not doing as good of a job with our LGBTQ birth, parents start to measure that so that we can see when we implement an intervention, how that changes the needle or doesn't or worsens gaps for some of those communities. So every QI project should have that equity lens and should be in the protocol. It should be stated from a fundamental, burly meeting first meeting, like how are we going to measure and make sure we're not worsening disparities? But the same can be true for research to me, there is no research question where if you at all, are studying something where there might be racial disparities, you may have to be cognizant of that possibility. Be understand what race measures, see then name that in your research approach, which means it should show up in your maths paper and research. And then see, like should come come back to it and your discussion exactly, like what was the impact? What could this be? Because for far too long, our research papers have just noted disparities and lead to these misconceptions about racial disparities actually represented. So but without those, like naming, in those first meetings, whether and I know I'm focusing on research and QA because that's my, my focus, but it can also be part of it. And it should be a big part of, you know, Nicu doctors or Nikki clinicians who work in recruitment and administration and hiring practices, those who are involved in hiring nurses and hiring our teas and hiring our lactation consultants, this, these are tenants that you can apply to any hat that you wear, within NICU medicine. I've done?

Daphna: 33:28

You're not done? Don't Why not done that? You're just planning my turn. Right. But so my question. So I think, you know, we've been reviewing a lot of papers. And so I'm just reminded when we do the Methods section, right, that the we keep talking about how we need more granular data to distinguish one type of baby from the other and I mean, pathologically, right? Not even the work that you're doing. But that's exactly it. When we look at the methods and they talk about race or sex or, you know, socioeconomic group, there's only two or three groups when we know there are hundreds of groups. And so I think that's potentially somewhere where everybody can make a difference is by breaking down your groups a little bit more and trying to find the differences, like you mentioned, I think that's a great takeaway point that I hope people feel, and that you talk about those differences. At the end of the paper, like you said, in your conclusions. One of the questions I have and we have a lot of trainees who listen is that this whole type of work is kind of a disruption to how we do academic medicine, right where the quote unquote gold standard is the randomized control trial. And I think that you're proving that for certain types of questions. We we need different types of work. So how how do people not just in this in this You know, genre of research, but how how to new people try to prove to kind of the typical hierarchy that and this type of work is important and has value even though they may not understand kind of the methodology?

Unknown: 35:18

So that's an excellent question. And I really appreciate you asking it, because it's something that I've already experienced, even in my like, relatively short career as people sort of asking me to justify some of this work indirectly or indirectly, and trying to kind of set it against traditional benchmarks of what rigorous science it should be, and what types of science we should be investing in both concretely with money and in people's time. But, you know, I think one of the things that I've learned, and that I continue to learn is fact that when we were doing this type of work in terms of whether we call it health equity work, or health disparities work aimed at correcting inequities, or anti racist research or anti racist work, which is sort of the frameworks and the mental models that I've started to move towards to describe my work. It really is a way of improving healthcare in society, and improving the quality of the health care that we provide. So we said this a little bit before, right, if, if quality is is is a characteristic that we value in medicine and science, which I think we all agree that we do, then we have to find ways to improve quality for all the patients that we serve. And that to me is fundamentally what health equity research does. Does it sometimes use different methodologies? Absolutely. Does it sometimes use the same methodologies. Also, absolutely. Like I definitely see some of my colleagues who are starting to use quasi experimental research methodologies to try to get at a structure as you know, randomize as one can be in terms of evaluating policies and laws that may or may not be tackling structural racism on a societal level. So there's definitely ways to utilize research methodologies that people have traditionally used for, say, evaluating drug A versus drug B, to evaluate policy a versus policy B, both at a microcosm within a unit, a macrocosm within a city, state or country. So we can use some of these methodologies that we're familiar with. But if we are honest about providing quality within medicine, then we have to understand that some of these research questions can't be answered with big datasets and some of these RCT type of methodologies that we traditionally value and that we do have to start to do more mixed method in an iterative work that gets at change much more quickly. Because the truth is, you know, and I think you guys are familiar with this as Journal Club experts now, like when we do when we do type of like RCT type of research, it takes a long time for that data to percolate into the literature to affect clinical change to turn into the kind of change that we see affecting the neonatologist daily practice, right, it's taken decades, for some of the keep returning to the steroid episodes, they just listened to it. But it's taking decades between some of the earliest steroid studies to really start to shift needles on steroid use within NICUs. And that kind of pace just doesn't work for health equity. And for health disparities, we have to be able to iterate quickly, we have to be able to get feedback quickly and incorporate that feedback quickly. Because if not, what's hot, what's happened, what will happen is what has happened in the past, which is outcomes haven't changed. Like you look at these graphs, and while infant mortality rates and preterm birth rates have come down, like the gaps have remained, and there's been no change over time for decades. So if we really want to disrupt that we have to be willing to disrupt what we consider the most rigorous and the most appropriate methodology to address the gap.

Daphna: 38:59

So obviously, your your area of interest is in patients, right? Pregnant, pregnant people and neonates, but I wonder to really do the work that we have to kind of disrupt everything we do in medicine, to kind of evaluate it through that lens. And so I wonder, you know, what, what can we do in our systems and in medicine, in general, to to bring that to fruition? Obviously, the terms like Dei, you know, are very, very popular right now, and everybody's trying to claim that they do the work. But how can you know, what are some things we wanted to talk about some of the concrete things we can do in the NICU, but I kinda want to start big and move small. You know, what, what, what do we do to actually like you said, move the needle and from from our bed bigger systems so that we can translate that to patient care?

Unknown: 40:04

Oh, that's such a good question. And it really allows me to expand on another kind of area of my work that has really been filling my cup of lead, which is mentorship, of underrepresented minorities who are trying to minoritized people who are trying to enter into science and medicine, and more globally, like recruitment of people from those communities into medicine and science and academia. And I think that is fundamentally something that is not just the purview of a dei committee, but really anyone who's who's within medicine, but I'll explain so. So for instance, in the social awakening, right, you mentioned like there's so many new or reinvigorated Diversity, Equity and Inclusion committees, positions, titles, roles, or at least statements. But one of the most, hopefully, most important things that will come out of this that I hope will come out of this is that we really start to change the face of who is practicing medicine and who is conducting science, and who is gatekeeping, what science is conducted at what what kind of science is conducted, and what medicine and medical practice looks like. Because we know that diversity at every level improves outcomes. We know that from gender equity literature, we know health outcomes improve when you have gender diversity. We know that from racial ethnic diversity literature, in terms of health outcomes among populations that are diverse, we know outcomes improved. So changing the face of the community is a big concrete part of what the AI efforts should really lead to. But in order for it to lead to that, it can't just be a handful of people within every unit or hospital doing this work. We can have these committees of people who are like, Okay, well, what how can you make a unit more diverse? And how can we recruit people who are more diverse, but part of a fundamental tenet is that recruiting diversity to medicine means creating medicine create or changing the culture of medicine to be more inclusive, welcoming and fostering the careers of people that you then recruit. And that's everyone's job. And so what does that mean? Concretely, it means that if we're committed to changing the face of medicine and making it more diverse, than we all need to start to recognize the implicit biases that we walk through the world with, and how those implicit biases may or may not provide a lens where we see or don't see things that people from a different background are living through. I think that's something that everyone who practices medicine should, like come to terms with. And you know, everyone has, like implicit biases. We know everyone has them. We know they impact health care delivery, we know the impacts health outcomes, we know they impact things like pain management. in pediatrics, there's there's great literature coming on some of my amazing colleagues, some of whom used to be here, Dr. Tiffany Johnson has done great work about implicit bias and health outcomes. But we know they're they're acknowledging the fact that they're, they're not fighting this feeling of, you know, I I'm not I treat everyone the same. I don't have biases, like that's a natural response. That's a natural inclination. It's a human inclination, especially for those of us in medicine to want to go to want to fall back on but doing the work of just internally acknowledging we all walk through the world with biases, how does that impact not only the care I deliver, but how I exist within my Niki within my division? How does that impact whether I say something, I notice that an interaction was potentially harmful or detrimental to my colleague of color? How can I be an ally? How can I turn that into a teachable teachable moment for any trainees that have been witnessing it or any, you know, nursing staff that might have witnessed it? How can I change the culture within my little microcosm of how I walked through making medicine every day? That's something that whether you're an attending a fellow or resident and nurse and RT you know, everyone can do and that's how we shift culture. So that is fundamental dei work, but it's outside of DDI committees. The committee's can suggest this type of work and inform divisions about the importance of this work, but it's on everyone within the NICU to really take on that personal work. Separate from that isn't how do we recruit people that can offer racial concordant care or language can coordinate care? So that's really on administrators and people who make those decisions as to how can we disrupt how we recruit how we evaluate potential applicants at every level, whether it's applicants and medical school applicants, residency applicants, the fellowship, that's what I'm involved in right now, applicants to early faculty, how can we disrupt how we recruit people how we evaluate whether They are a good fit for our units. And how can we ensure that if we do recruit them, that we are fostering their success and their longevity within our units, that again, is something that note like the people that might be involved in DDI work should contribute to but that goes beyond the EI work, it goes to everyone who serves any kind of role on a on a hiring position within an institution should work on whether it's the person sending out the email invites, or the person doing the tools, or the people interviewing like that falls on everyone outside of dei committees. So those are some of the things that I think are really important, because that fundamentally will change things if we can change if we can reflect the communities we serve. health outcomes will improve.

Ben: 45:44

I think that I have a question, I'm not sure if I can, how to ask it. But I feel like D I work sometimes will turn off the segment of the population. Because the fact that we're identifying something that is systematically wrong with our current system makes people believe believe almost by syllogism that like, then you are the problem when in truth. And so people say well, they just I think intrinsically did this, they want to believe I'm a good person, I didn't do anything wrong. And so I think by engaging with this type of work, I will sort of acknowledge the fact that I'm part of the problem. And I don't want to be a problem. I want to be a solution. And so how do we negotiate that sort of difficult interaction with people who are not deeply invested in this field? To bring everybody to the table?

Unknown: 46:41

Great question. And once again, you hit the nail on the head on what makes this really challenging, especially because a lot of the EI work across the country is LED or asked of people who come from minoritized communities themselves. So you see a lot of people who wear these identities, who are then trying to convince people who don't wear these identities of the importance of this work. And responses, like what you mentioned, are really common, I see them. I've seen them in any context that I've worked in the neck, but I think like something you just said is is really important is that we all have a desire to be part of solutions and not the problem. But to really understand take that step and say, to be a part of the solution, we have to acknowledge that we are all part of the problem is an initial first step, because it immediately gives you moves you into that action oriented, action oriented phase, right? Because we can decide, you know, I am this work is important. I can see it as important out there. But it's not applicable to my practice, or my life or my research, or my Qi endeavors, because I'm not biased. And I know that I do these things. So the very first step is acknowledging that all of us hold different potentially biases, that we all are impacted by structural biases differently. And that acknowledgement is part of the solution. So it seems it seems my new like this mental shift of saying the acknowledgement of the problem is acknowledgement of how we move towards solutions. But it's fundamentally important. Yeah, I

Ben: 48:23

think it's the linchpin, it's the linchpin to the entire process, right? And that,

Unknown: 48:28

you know, that is something that we all have to work on. And we all have to continuously risk. I'm not saying I'm immune to that, like, I constantly have to reassess where my biases impact my work. And I like, like, I'll be very honest, I, I am a white, represented Latina. So I have to contend with what that means in terms of how, as a racial ethnic inequity researcher, how that impacts my work, because I don't have the perspective lived experience and historical framework of being a woman, like a woman who is black or a person who is African American, or black Latina, I don't have that perspective. I don't have and my bias is that I can't, that I have to assume I have to make sure that I'm not assuming my white Latina perspective is representing black Latinos. So that's personally my my struggle, but we all have to just acknowledge what it is that lives in our minds, and how that impacts our work.

Daphna: 49:27

I love that you mentioned that because I think a lot of people think like, okay, we're doing minority work, we'll just put all the minorities in, in one group, but, you know, you're you're that's really the that's really what you're saying is that, you know, we even as a minority group, we can't identify as any other minority group. And, you know, my background, I come from a mix of minority groups, but like you said, I don't have any telltale signs that I belong to any of those minority groups. Oops. And so I wonder for people who are new to the lingo, who are just, you know, we're just trying to do the right thing. So how do we know? What we don't know? And how can people you know, who look and sound like me be? And again, our listeners don't know why. But, you know, how can how can we be allies? If we're still in those kind of initial stages of understanding what all of this means?

Unknown: 50:30

Great question. So I think, I think it's hard, I'll just start by acknowledging that it is hard and it is constant. And so it is, it is work, you have to be concrete about, it's not something that you're just going to need your to right away, especially if you have this far live life through identities that encompass lots of different privileges. But one of the main important tenets to me is understanding what our identity is, and how identities can impact outcomes differently. So, for instance, what that means is, I know that as a white passing Latina, that my experiences as a mom, as a physician, might be different than a black, a woman who identifies or is perceived as black, by society, within medicine, or within a parenting role. And wanting, you know, looking for ways in which wherever at whatever role I'm, where I'm engaging it, whether that's, I'm the neonatologist on service, or I'm the Research, like PII in a study, understanding that my experience might not be everyone in the rooms experience, starting from that fundamental perspective of my reality might be completely different from someone else's reality, who's sitting next to me in the same room experiencing the same set of circumstances. Because I think one of the hardest things is to say, you know, this was not my experience, I've never seen someone be discriminated against, I've never experienced, you know, person A be treated differently than Person B, or what you know, what it's like to live in neighborhood a versus neighborhood B, or in a state with policy a versus policy B, you can take it at every level, like I've never experienced that. And therefore, you know, is it true that that experience could impact it could be what you're saying, and this questioning of someone else's reality. Fundamentally, what everyone can do is start with this understanding that our reality could be completely different from someone else who's getting exactly the same who's living through what could be perceived as exactly the same situation. And when you start with that, like, shift work shift, like mental shift of like, someone could be in my shoes and have a completely different experience. And you allow yourself the possibility of considering that then a, I think what could happen as you start to see how certain circumstances actually are very different and just never noticed that before. Or be at least create space, when people start to share some of those experiences. Without the knee jerk reaction of like that camp, that's probably not applicable to my life, or to my practice, to create space for that different experience allows us to then have a conversation about what to do, and starts to set the groundwork for being an ally, when you start to notice those situations. So I'll give a very concrete example. Because I know that's like very, like abstract and vague, one of the things that we are starting to contend with in our, in our hospital system is that we definitely see and have discussed on a divisional level that there, there tends to be practices patterns where hospital security is seems to be called at higher rates on families of certain backgrounds, certain histories, and certain skin colors. And we're starting to contend with that through lived experiences, case examples. And when we have these discussions, it's painful, it's hard. It's hard to think of us applying a hospital policy, a very, like discrete hospital policy differently. And there's always this inclination to be like, no, no, it's just a policy, we apply it the way that it is. But when you have people who are working in the same environment, telling you like it, this is different, it feels different. Starting to create space for that difference, can then lead to like concrete solution, building conversations, but it's hard work and you have to be okay to sit with that discovered. And so that's the very first step. Go ahead, Ben.

Daphna: 54:45

You're gonna let me go. You're gonna let me go. So and we've done a lot of talking about I brought us out to the big picture of medicine, but we promised people that we would give them some, you know, real are identifiable things that they can do in their daily practice. So one thing I heard you say is that even though we're pediatricians, and we're neonatologist, we have some pediatric intensivist. We take care of babies and children, that we should care about parents and the things going on in their lives. So I wonder if you can give us some examples of, of how we might change our practice to include some of the other things going on in parents lives other than just our updates, and then also some of the definitive things we can do for the babies in our care?

Unknown: 55:45

Absolutely, you know, it's not I'm not gonna, I'm not gonna say something that I haven't potentially said. But I will reframe it to because I think it's that important. I think one of the main things that we can do is recognize how the things that are happening for families outside of the Nikki wall are incredibly important to the outcomes that we are measuring and hyper focused on within the walls of our NICU. And they are especially important to the outcomes of our babies after we release them from the walls of our NICU. Right, so we we appropriately pour lots of time and energy into figuring out what is the best way to mechanically ventilations preterm babies, what is the best strategy to feed them? How can we diagnose infections and treat them in a way that is safe, but also, you know, has great stewardship practices, we invest so much time and energy into those practices and we should, but that level of time, and concrete investment through funding and money that leads to programmatic infrastructure also has to be invested in how can we be building up these families and their familial contexts through the entire NICU hospitalization, so that when we discharge these babies that are medically fragile that are to increase risk of morbidity and mortality after the NICU increases the readmission, increased risk of mortality. How can we how can we be sure that we have used that hospitalization to ensure that all everything we did has longevity has legs? How can we be sure that they're going to go to their NICU follow up appointments because we have identified that they have transportation barriers, that they have language barriers to making appointments that they are going to have food security with any tiny disruption to their income? This is some of the work that I that I am starting to work towards publishing now is I worked with an incredible colleague here, Dr. Andy Duncan, who, when the pandemic started, she pivoted really quickly to making sure that with every telemedicine visit of our families in that initial, you know telemedicine epic. When COVID was at its worst in March, April, June, July that we weren't they were asking in NICU, follow up families about very concrete hardships and stressors that they might be experiencing, like, Do you are you able to get the formula you need for your baby? Or are you able to go to your follow up appointments? Are you having trouble accessing diapers right now? And ask those questions really concretely. And you'll see in the paper that we hope to publish in the next year there was, you know, incredible food insecurity, which should not come as a surprise given like the patients that we have, but food insecurity for an X preemie baby, who's our oxygen is a big deal, right? Like if we cannot set these families up for success after we discharged him from the NICU. What are we doing? If they can't, they can't access the formula, the like calm appointments, the like oxygen tanks that they need? After we've invested all this time and energy in that, what are we doing? So the to go hand in hand, and they have to be thought of as a continuum. And the same amount of energy and investment needs to go through that entire picture.

Daphna: 59:00

Yeah, and it's and it's not just our minority patients, right? These these external stressors really affect every single, every single family we interact with. The stressors are potentially different. And they may be magnified by some of the other things going on in society, but it's really every patient that we have to worry about and find out why their context is different than somebody else's.

Unknown: 59:28

And I would argue that's all of our responsibilities. Right. And I think that's one of the that's one of the things that I feel really strongly about is that that's not the purview of Social Work. Right. That's not the purview of, you know, case managers. I think as neonatologist, as physicians as clinicians, we have to know what context our families live in. We have to it should be impacting our medical decision making. In fact, if we if we really want to practice shared decision making family centered care within the walls of our NICU We can't do that without understanding what that family truly looks like and what their life looks like. So that is something that we absolutely need to do and we can. And I think one of the things that is tough, right is is this idea that like, Okay, well, neonatologist or clinicians have this task. And social workers or case managers have these tasks and like subdivision of labor. But similar to what we talked about in terms of research, like that siloed approach is exactly how unnoticed gaps and safety nets that don't exist, keep being unnoticed. And so, it is possible for neonatologist and physicians to be informed aware of and have that impact day to day medical decision making. like it should. And it should, right so like this is the I need to know whether the reason a nurse tells me that mom is never there is because she's trying to work three jobs, whether the reason she is running out of breast milk in the in the in the in the in the milk bank is because she never got the pump. And I need to know that are the neonatologist like an I need to think about how my medical plans can can coalesce with social work to be able to support that mom in the NICU like that is something that all of us need to have friends of mine.

Daphna: 1:01:12

And that happens every single day on rounds where they say, well, mom's out of milk, we got to think about our formula transition plan. And you're like, Why? Why? Why do we have to think about that? Did you know? Has anybody talked to mom? Yeah. Has anybody talked to mom or dad or grandma or whoever, you know, the baby's care team is, you know, every single day we have that opportunity ask why

Unknown: 1:01:38

and then develop the policies that create safety nets. Right. And so that's the but the, but you can't even develop policies that are safety nets. If you've not asked the question why and you just need your like order the formula with fortification? And then and then you wonder why at discharge on some families have significantly lower rates of breast milk provision.

Ben: 1:02:01

Yeah, I mean, this is this is fascinating discussion. And I feel like Daphna and I have tried, in our own units to really try to create a space for families to set the stage. So for, for example, at family meetings, or on rounds, we both make a point to not have anybody speak before them, right. I mean, if you go to a family meeting, it shouldn't be anybody from the team starting the meeting, the context should be placed by the family, because then if you establish a framework that is radically different than I think families just try to fit into whatever you're placing in front of them. And that can be that can be difficult. And that's where I think all these inequities and biases come into play. So it's hard. And what you're not underlying is the fact that, like you said, everybody's situation is unique. And it requires unique work. And yeah, if if we could have more time with the families and less time writing notes. I'm not going to touch them.

Daphna: 1:03:02

And I'm cognizant that we're, we're running out of time, we have so many more things to ask you. But I think even that, you know, what do you think are the ways that we can best, best engage our families to get the right kind of information, because so many of these things are sensitive, or parents don't want to tell us for so many reasons, they're embarrassed, they feel guilt, they feel pressure, they feel like they can't, they're not doing what they need to do to make, you know, their baby thrive, when we know they have so many forces that they can't fix on their own. So how, you know, how do we do that? How do we what sort of narrative medicine approaches do we do to get this information from families?

Unknown: 1:03:55

I think it's interesting that you just use the phrase narrative medicine approach versus knee jerking to like, what surveys do we need to be administering our families? Because what I was gonna say is, I don't have all the answers for what the right way to do that is within every clinical context. But what we have what I do know in terms of some of the things that we should learn from in the literature is that implementing social needs surveys, without having a reason and plan for what to do when social needs are identified is not in our family's best interests, and can do exactly what you imply, which is be really stigmatizing and ultimately counterproductive to what we're trying to do. So the answer isn't just blanket social needs survey implementation. You know, let's ask all these difficult questions of our families on admission on a regular basis, make them fill out the surveys are asking these questions like maybe that's part of the answer. If we have a pathway for how We're gonna use those answers in a really tailored way. And we have programs and pathways and processes that we can adapt. Maybe that's the answer. But we know that the implementation of a social survey need alone without having thought of that process from the start is not is not accomplishing what we hope to accomplish, which is a lofty goal, which is a good goal, right of making sure we're asking families, it can have unintended consequences. So but when you say narrative medicine approach, it brings up this idea that like, maybe part of the solution is more of a narrative approach to gathering some of this information from our families. And like I said, I don't know all the right answers. But I do know that in my interactions with my patients, some of the most useful data that I can then use to apply to my medical decision making comes from the afternoons where I wander the unit and start to just sit and chat with families. Can we can we do that on in a systematic way? Potentially? Can we teach that? Absolutely. Can we incorporate that into our medical education also? Absolutely. And so how do we how do we take some of those practices, systematize them, study them, make sure they're having the intended consequence. So that we are gathering the information we need from families in a way that's not stigmatizing that's not distancing, and really turning it into the data that we can use for a family's best interests. I think that's going to require individual work within units. And maybe people who do that kind of work writing about it, writing about their experiences, writing about what worked and what didn't work, right, sharing lessons learned, it is so important to write up Qi work or these types of initiatives, because we need to test them in other contexts, and we need to hear what worked and what didn't. And anyone can do that, like research and science should not be gig. Like we all need to learn from each other. And this needs to be valued by people who find the time and valued by journals. So that's, I think, the beginning of that.

Ben: 1:06:58

I had an attending in New York when I was in residency that used to say, don't think about the questions that the parents asked but wonder about the questions they haven't asked. And, and that was always a very cool trick as to why has this family not asked me about when is their baby going home? Right? I mean, that is, that's should be just as peculiar as any other odd question that a parent would ask. And I think that sometimes when the things that are not being said, could be very revealing of a person's sort of situation and limitations and pressure points. And and that's, that's something very, that's a very interesting game to play with, with your, your population and your units to see because you will unearth a lot of different things that will impact care directly, in my opinion.

Unknown: 1:07:45

But I think that it shouldn't be up to someone whether they have an attending who can exemplify that kind of behavior. I think that kind of educational pearls should be systematized in medical education. Right. So that's how you turn some of these things into systematic policies to address systematic differences, like medical education reform is wildly important to this work.

Daphna: 1:08:08

I have one more question, then I'm gonna let Ben close out the show. But I am sure there are people maybe they haven't made it this far on the episode who are saying, you know, I still don't really, I still don't really get it. And that's fine. So why don't you tell us? You know, the top three reasons why as someone who cares for neonates, we have to I think you've touched on a big one, which is breast milk provision. Give us an another to why you say you, it has to matter to you, because this changes outcomes in babies.

Unknown: 1:08:42

So I guess for the first one, that's a big ask Daphna to like close them. Still into three bullet points, why health equity work? Go. But I think, you know, for me, one of the things I returned to that really guides my quantitative and qualitative work is something that I learned early on when I started engaging in epidemiological, and that's that it is, it should be shocking and motivating to all of us in the perinatal space, what infant mortality rates are alike in this country. And in developed countries, even in lower to middle income countries, but especially in developed countries. That should be shocking to us. And what we know from data is that infant mortality rates in the United States are driven a lot by postneonatal mortality, which is that mortality that happens after the first 28 days because which is a lot which is driven by lots of factors that are modifiable, right early in early neonatal mortality has a lot to do with congenital anomalies and then preterm birth. And we can have a whole discussion about how we move the needle on preterm birth or not at a different time, but postneonatal mortality, lots of modifiable risk factors, and postneonatal mortality is also where we see time tons of racial ethnic inequities. And so we haven't shifted the needle on racial and ethnic health inequities and postneonatal mortality. And as a result, as a country, we haven't achieved infant mortality rates that we should be proud of. And so anyone in the perinatal space, who is interested in improving infant health, which I feel like we all should, should look at infant mortality rates and be like that is the reason why this work is important, because we cannot fix those interim infant mortality rates until we address the elephant in the room, which is that until we address structural and individual inequities, we're not going to shift the needle, we're not going to catch up to under to other developed countries. So that to me is primordial is, is recognizing that this work impacts how many babies die before they reach a yearly. And then

Ben: 1:10:49

that's very important for you to mention that we're not You're not talking about ELB W's there. I think many people will say, well, in America, we have great survival rates for ELB W's compared to other countries, you're talking about full term babies. And sometimes we tend to forget that these babies do die. So like, I just wanted to bring them like

Unknown: 1:11:07

the whole, the whole set the whole cohort of babies who live past the first one eight days VOB W's and not right, because that gets to what are we doing for ELB W's after we just turned them from the NICU. But um, so that's, that's, that's point number one. But like point number two for me, is that to me, you know, I've struggled with, do I promote this work as social justice? Do I promote this work as quality? Do I promote this work as the economically good, like reasonable thing to do in medicine? And to me, the truth is that I can't pick one, right to me, like working to narrow inequities in health outcomes, narrow inequities, and health care access, narrower inequities in the quality of health care delivery, is ethically and morally the socially jesting to do is the right thing to do if you're trying to impact quality metrics, and is also the way we save health care costs and make financially savvy decisions within healthcare. So you know, if you think about it, in terms of that spectrum, that it is the right thing to do. But it's also like the economically smart thing to do, and the way that we should be structuring insurance pay backs and like quality metrics like that, if you're hitting all of those boxes, like what's the rationale for not engaging in that type of work? That's great.

Daphna: 1:12:34

I think you summed it up, what else can I say?

Ben: 1:12:39

I want to fit Yeah, I want to I want to let the the episode finish on that it is the right thing to do at the end of the day. And that that's that's what should matter most salutely.

Daphna: 1:12:48

Dan, it's been a pleasure. It's nice just to see your face. We miss you so much. I invite everybody to take a look at some of the things that Dr. Montoya Williams is doing, and what the Child Policy Lab is doing. And maybe we can add some of those links to the show.

Ben: 1:13:09

I was gonna ask, do you mind if we share your email address on the shot? So if somebody wants to reach out to you for that type of either mentorship guidance or

Unknown: 1:13:17

collaboration, mail, Twitter, share it all?

Ben: 1:13:20

Okay, you got it. Thank you. Well, go ahead. Definitely.

Daphna: 1:13:23

I said we, we didn't even touch on the mentorship work that that you're doing and how early you got into mentorship, right? So send those emails.

Ben: 1:13:34

I was gonna say we haven't touched on motherhood and medicine. Anyway, Diana, thank you so much for your time. It was a pleasure.

Unknown: 1:13:42

The pleasure is all mine. I am excited for what you're doing and to be here. Just continue to do this work. It's so important.

Ben: 1:13:50

Thank you. Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcast or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikhil spelled Dr. NICU. And Daphna is at Dr. Dafna MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you