#027 - Dr. Benjamin Rattray - On the impact of stories from the NICU

Dr. Benjamin Rattray is a newborn critical care physician in North Carolina where he serves as Associate Medical Director of Neonatal Intensive Care at the Cone Health Women’s and Children’s Center. He completed a pediatric residency and a neonatal-perinatal medicine fellowship at Duke University Medical Center, holds an MBA from LSU Shreveport, and is a Certified Physician Executive. He lives with his wife, three children, and a Golden Retriever in Greensboro, North Carolina.

He is the author of the book WHEN ALL BECOMES NEW: A DOCTOR'S STORIES OF LIFE, LOVE, AND LOSS.

Learn more at benjaminrattray.com.

Purchase Dr. Rattray's book on amazon @ https://amzn.to/3juLpfv

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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: 0:46

Hello, everybody. Welcome back to the podcast. Definite hasn't been going. I think we recorded yesterday.

Daphna: 0:51

So that's right. But for the listeners, it's been weeks. So for everybody following the saga, but the puppy is sleeping through the night. So I'm doing and very, very excited for who we have on the show today. How are you doing this morning?

Ben: 1:07

I'm doing fantastic. We've been we've been so busy. But it's good. I mean, I enjoy the opportunity to get to do some of this work both in and out of the NICU. So yeah, and I'm excited about our guest today. So without much further ado, Dr. Benjamin Rattray is with us today. He is a newborn critical care physician in North Carolina, where he serves as Associate Medical Director of the neonatal intensive care unit at the Cone Health Women's and Children's Center. He completed a pediatric residency and neonatal perinatal medicine fellowship at Duke University Medical Center holds an MBA from LSU Shreveport and is a certified physician executive. He lives with his wife, three children and a Golden Retriever in Greensboro, North Carolina. He is the He is the author of the recently released book when all becomes new, Benjamin, thank you so much for being on with us.

Benjamin Rattray: 1:58

Thanks so much for having me.

Ben: 2:01

I guess the way before we get into the book and what you're writing about, I wanted to know, can you tell us a little bit about your background? And how does that translate into you becoming a neonatal intensive care physician?

Benjamin Rattray: 2:17

Yeah, so my background is, you won't hear it from the accent. But I was actually originally born in New Zealand, and then bounced around a lot of the kids so moved to between New Zealand, England, Australia, San Francisco, and then ended up in Southern California. So I went to undergrad in Southern California, started off actually as an English and psychology major, and then switch halfway through college into pre med, and then stayed for medical school in Southern California. And then came out to Duke University for the trick residency, and then stayed on for fellowship.

Ben: 2:58

Very cool. And and so throughout this, this path of yours is there. What What led you towards a career in the NICU? I mean, it's such a stressful environment that we're always very interested to find out what are the motivations of our guests to pursue this field?

Benjamin Rattray: 3:15

Yeah, yeah. So I think like a lot of us, it's sort of a circuitous route. But I ended up doing an abnormal psychology course, in my undergraduate years and decided that I wanted to go into medicine, I wanted to do something that was more kind of active with my hands. So instead of just doing psychology, where you where you talk to people, which is really important, and a really important thing for people to do, but for me, I really wanted to be in the hospital working with patients. And so at that point, decided to change to pre med. And I read a book that was really influential for me called when the air hits your brain by the author, Frank bird is sick, that came out, you know, sort of the time that I think all of us were in college, and it's tales of the neurosurgeon, so I fell in love with neurosurgery and I thought that that was what I was going to do. So I did a sub I, during medical school and neurosurgery and identified a program and was sort of all set to do that. And then at the same time, I was I was somewhat, you know, interested in pediatrics and ended up getting a sub i in neonatology for some reason, the nurse surgical unit was sort of close to the NICU where I was doing my training. And I think I somehow sort of became aware of the NICU and got really interested in that. And so when I did that sub i in neonatology sort of everything clicked and I realized that was really what I wanted to do. So then, when I went into my pediatric residency, I definitely had some times where I wondered if I wanted to maybe do peds Ed, or and I love to pick you. But ultimately, every time I was back in the NICU for some reason, I felt like I was home Um, even though you know, as you're reading the book, it's terrifying as a trainee, you know, it's terrifying as a medical student. And even as a resident, you know, I think all of us probably have that that similar experience where you're just praying that you don't somehow dislodge at Sinai or the UVC falls out, you know, you feel the nurses are just, you know, watching you so protectively, which they should.

Daphna: 5:24

There are still days where it's terrifying.

Ben: 5:28

Right? That's right. So you recently published your brand new book, when all becomes new on September 9. And for the listeners who haven't yet read the book, or who are planning to get the book. First of all, the book is available wherever books are sold, and the book is broken down into three parts, right? I mean, there's the first the first part is training. It's called training, then young attending and becoming. And throughout the book, you share stories from the NICU that really span the gamut. I mean, there's everything and everything in there from the highs to the lows. I was wondering, before we ask you more questions about that, can you can you tell us in your own words, for the for the audience, a short description of what the book is about and what it means to you to have written this book?

Benjamin Rattray: 6:17

Right, yeah, so this book, is a collection of true stories. And you're right, it does span the time from training to young attending. And then the last part is called Becoming. And that's, of course, where I think I'll always be. It's, it's kind of that stage in your career, where you've been out enough time, you've seen most things, but you're everything is always a challenge. But each chapter is a different patient story. And they really range you know, from an airborne transport to pick up a baby, I'm dealing with things that we commonly see in the NICU, like sepsis or Hae. But each story is one that kind of grabbed me as I was going going through it, and really kind of lodged in my memory was something that I would would often think back to.

Daphna: 7:06

I had a question, specifically, actually about the layout of the book, because I think as a reader, I loved that that's how you did it and kind of your career chronologically, because I felt like we could even see you developing as a physician, because you talked, you tell us a story, but so much about what you what you write is your emotions and how you're processing that. And so I really felt like we we could see your progress, even as a physician, and for a physician. You know, it added, you know, the NICU stories are interesting, especially if you're not in the NICU all the time. And Ben was talking about this before we're rootin for you and for the babies, right, because we've all been in those situations, but hearing your your own kind of self dialogue, I think was so valuable. And I'm sure as you were going along, you wondered, how will I arrange this? So what made you, you know, pick this order? I guess?

Benjamin Rattray: 8:05

Yeah, that's a great question. I actually started out with sort of this random assortment of stories, and was trying to figure out how to put them together, and how to have some sort of narrative arc of the book. And I actually had times where I had index cards spread out, you know, all over the kitchen table. Index. That's right, right, right. You know, how do you how do you put this into a cohesive whole? And what sort of came out of that, as I realized so much of my own story, was that story of going through training, and getting to a point where I am today. And then part of that journey, as well was really that wrestling with? How is it that these really, you know, sometimes really bad things happen to people? And how do I maintain my own faith in light of seeing these things. And I realized that that was actually a journey that I had gone on as well. So I've gone through this medical training, but I've also gone through a pretty significant change myself, you know, from those early days. When, you know, of course, I think, like most of us, you start out really idealistic. And then, you know, you encounter these difficulties, and really start to wrestle with, you know, those those beliefs that I had held before training, and then also trying to work out how do you interact with the outside world, you know, when you go to the grocery store, POST call, you know, to grab a gallon of milk, when you've just pronounced a baby dead in the NICU, you know, an hour before, you know, you just have these really abrupt transitions. And so a part of it was really working through that and then coming to the place where I'm at now, which is which is not a place of complete understanding, but it is definitely more nuanced than where it's Florida.

Daphna: 10:00

Yeah, I love that you called that last chapter becoming because you didn't call it like, arrived. Right? Right. It's still a process even even when you're out of training. And I think some of those debates we have with ourselves, you know, where we'll be ongoing, I think even after we retire, potentially. And I thought that was so valuable, I think for people who don't understand what's going on in the NICU, for people who are training and going into the NICU for people who are you know, like, like Dr. Kirsch and I are still pretty early in our careers. I think this was a really a valuable book. For those reasons. Specifically,

Benjamin Rattray: 10:42

thanks, you just gave me an idea for the next book, which will be arrived. Unfortunately, that that will be the book that I will never think we'll ever get to that point.

Ben: 10:53

You touched on so many subjects in your last answer. So I'm going to try to take it one at a time, I wanted to ask you about your motivations for writing. And you mentioned the stories, but I want to I wanted to quote some of some of portions of the book to give people a feel for the book. And, and at some point in time, there's a story of the of the sniper son, right, and and you quote, and you mentioned, the reasons why you write and so you quote, Ford Madox Ford, and you say, quote, you may well ask why I write. And yet my reasons are quite many for it is not unusual in human beings who have witnessed the sack of a city, or the falling to pieces of a people to desire to sit down what they have witnessed for the benefit of the unknown heirs, or of generations infinitely remote, or, if you please, just to get the sight out of their heads. And I thought that was very powerful, right? Because I mean, those experiences in the NICU are very traumatic. But then I wonder is, is it only because of the traumatic experiences that that makes us that drives us to write? Or do you think that it is not the same from the positive experience, right, it feels like the trauma of the negative Trump's the, the highs of the positives. And I'm wondering if you felt that when you decided to put pen to paper?

Benjamin Rattray: 12:15

Yeah, those are great questions. So the truth is that I started writing to share these stories with my family. So I thought when my kids are older, when they're old enough to read these stories, I would like to share these stories with them, so that they can kind of see what I do. And also with my wife, because, you know, there, there are quite a few of these stories that actually a lot of the stories she had never heard, you know, I would come home, and I didn't want to talk about them, and I wasn't ready to share them. I didn't know how to communicate them to her. You know, there were times that I would attempt to, but you know, we were raised, you know, we're raising three kids, and there's always kids around and you can't talk about a lot of these stories with with a little kid that are listening. So that was part of it was to sit down and and share these stories. But then I think part of it is, as you pointed out, in that quote by Ford Madox Ford is part of it is also to get them off our chest. And I think you're right, you know that the tragic things are the things that we really want to get out of our heads. But I also feel like, you know, that profound joy in some of these just amazing outcomes that we have. And in neonatology, we're so lucky that so many of our outcomes are really great outcomes. And so I think there's a lot of joy in sharing those with people as well. So I think you're right, you know, it's both of those things, the tragic things can feel you're more emotionally heavy, and drawers and a little more. But I think these great outcomes are really important stories that we have to share with the world as well.

Daphna: 13:50

It's so interesting that you say that, I was telling my husband this morning, you know, we had we had Dr. Rat round today. And I said, You know what, I think you should read the book, because then you'll really understand what life is like, when I when I go to work, and I come home from work. So it's interesting that you say that and, and he's a psychologist, he's a great listener, you know, I'm pretty open about what happens at work even with my daughter, who's six, but I thought, you know, I really need I need you to read this book. So you understand what's going on. And that's

Ben: 14:23

the question I wanted to ask you is, through the book, I kept asking myself this question, which is, who is this for? Is this for you? Is this for parents? Is it for patients? Is it for colleagues? Because it's, it goes through it's so dense when it comes to the emotions and the descriptions that I've been wondering throughout the book, sometimes it's so wrong like I don't know if this is for parents, I mean, with parents want to really put themselves through this is this more for us, physicians and providers. But then again, when you talk about the experiences you've had in your community, then you say, well, maybe it is for parents or so. So I'm wondering if you have an answer to that. Yeah, it's

Benjamin Rattray: 15:07

been really surprising because I've been telling NICU as NICU parents, I mean, definitely parents who have babies in the NICU, but even parents who have gone through the NICU, I've been telling them, please do not read the book. You know, I told one, Mom, if you want to read anything, just read the last paragraph. You know, because unfortunately, she had lost a child in the NICU. And I felt like maybe that last paragraph would provide some comfort, but I really did not want her to read the book. And I also thought that people who work in the NICU would be sort of maybe even bored by the book, because they, they do this all day, every day. And so this has been actually the most surprising thing for me is that there have been a lot of parents who've gone through the NICU, who have read the book, and have given me really positive feedback. And I've really enjoyed reading the book. And I just didn't, didn't expect that. And the other surprise has been, the nursing community has really just rallied around this book in a way that I didn't expect. That's awesome. So you know, that my answer before was that this book was for anybody who likes medical narrative, you know, medical stories, whether that's called the midwife, Lenox Hill, you name it, you know, any kind of medical story like that. And I think that's still true. But I will just admit that I have been surprised by, you know, but the support from the nursing community and even by NICU parents, but I would still put that out there that I think that, you know, it should carry that sort of trigger warning that I think it could be difficult for NICU parents to read it.

Daphna: 16:48

I wonder, though, you know, it's, if it can help some parents, right, not everybody, but it can help some parents really feel that we feel the heaviness of, of the decisions that we make and their grief and the sadness, I'm not, I'm not sure parents always feel like the medical team. And we don't understand what they're going through. But we are attached to and we carry a weight with us and we carry what I think is so valuable, is we carry their babies with us forever, right. And for some parents, that's so valuable to just know that their baby only lived for a short time impacts impacted somebody. And so I can see why parents are drawn to the book.

Benjamin Rattray: 17:36

I'm so glad that you said that, because that's actually exactly what one parent told me was she she sort of communicated, I didn't quite realize how much the medical community cares. You know, I think we try so hard every day to show that empathy, to show you know how much we're wrestling through the decisions and doing the best we can. But I think that after she read the book, and she realized how much we bring home, you know, to our families, and how we keep it and like you said, how we keep these stories over the years. I think it brought her huge amount of comfort, knowing just our level of dedication and involvement.

Daphna: 18:17

Yeah, I want to talk about like, specifically that how, how we carry stories home. But before we lose the opportunity, I want to learn a little bit more about your process. Had you been journaling along the way? Or Did you really write these from memory?

Benjamin Rattray: 18:35

Yes, I actually just read them from memory, sort of sat down at the computer computer, one call night, and and started. And I wrote, you know, and I didn't really start with the intention of creating a book like this, it was just to kind of have a story to share with, you know, with the kids or with my wife. And I wrote that first story. And then I had another and then another and another. And I realized I had been holding all of these stories with me over the years. And then there were a couple of stories that kind of came up as I was writing, and I set those down as well. But I was really careful. Actually, I did not want to go back and do any sort of chart review or look back at any information. I wanted it to be purely the way that I remembered it. And of course, one thing to note too is a lot of these things are are changed in a way that you should not be able to identify with patients. So they come from about four or five different hospitals over a decade plus timeframe. And a number of things have been changed, you know, to try and preserve confidentiality with the exception of one family where I did an interview with with the with the mom, because I wanted more of her insight. And I asked her after I interviewed her would you like me to keep your your baby's names the same? And she said yes. So that's the one exception there.

Daphna: 19:59

And then is the story of the twins. It is it's

Benjamin Rattray: 20:02

the story of Paige and Reese, who were who were the twins? Yes.

Ben: 20:07

I think if we're talking about this story, it's it's such a powerful one. What I was struck by is how I was really thinking I was reading I initially, I thought I was going to read a book about the NICU. But in the end, I think it's more of the story of a community physician. Yeah, your bond with your community is so strong and the interactions that you're describing in and out of the hospital, really bring bring together the impact that a physician the provider can have on the community when when you see these patients and these families outside in a more normal environment. And and I think they counterbalance some of the of the loads that are described in the book when things really go awry in the NICU. And so I wanted to get your take on how important it is for you to have the sense of community of belonging, and really being not just a powerful force for good within the hospital, but within your immediate community outside the hospital.

Benjamin Rattray: 21:11

Yeah, thanks. That was definitely one of the things that I was hoping would shine through is that it's it's not simply a book of stories from the NICU, you know, because that's sort of a small niche area. And of course, it's interesting in its own right. But really, I think for us, you know, we are community physicians, we see our patients on the soccer field in the grocery store. Sometimes we even take care of multiple babies in the same family over a span of years. And so that's been really important to me, I've really enjoyed that aspect of working where I work. And that, that I do get to see my patients in that way. And I think it is, I think it's really important for us,

Daphna: 21:55

I did love, there are many times right, where you give us direct opportunities to see your interactions with with parents and how varied they are. And your own, you know, emotions, towards in with the parents and I particularly liked, and you telling us a story, in most of your interactions I can tell with parents are exceptionally positive. But about this mom, Harmony's mom, who was a frustrating, a difficult parent. And it was the middle of the night and you were already you had so many things going on in the NICU. This takes place in the exchange transfusion story. And so we can all imagine that stress of having a very defiant parent when you have so many other things going on in the NICU. And and we think it says a lot about you and you said Who was I to judge the roiling emotions of a mother with a sick baby and other children to care for at home. And it was such a reminder that so much there's so much going on with these families, other in addition to what they have going on in the NICU and we can't we can't truly understand. I wonder if you have any, you know, just kind of your How do you deal with parents? What's your you know, what's your tagline when you when you deal with parents in 30 seconds or less than 30? seconds?

Benjamin Rattray: 23:24

No, it's a great question. And, you know, I mean, there are the extremes of so for example, the story that you're talking about with such an extreme because, you know, this baby was critically ill, Nicu in this moment, it didn't take her home, that baby home right away. And I think that's actually a fairly common experience. And so it can be very frustrating. Because it seems, you know, intuitive to us, at least, that that's not a baby, that baby's not ready to go home. But I feel like the more challenging cases are, you know, maybe that that ex preemie who is not quite ready to go home, because they're not eating, you know, as well as they need to. But they're, they're getting pretty close. And when you look at them in the, in the crib, they look, you know, big and they look like they're ready to go home. And, you know, maybe they're just having some isolated events, and they're just not quite eating well enough. And that's the hardest part for me, because they really are so close. And usually the parents are so frustrated at that point. So I think to try and answer your question in 30 seconds or less.

Ben: 24:30

Just kidding about that.

Benjamin Rattray: 24:33

I try and be as honest as I possibly can, you know, and say, you know, I know how frustrating this is, I would be frustrated too, you know, by the situation. I try and paint that picture that we're both on the same team. Yeah, you know, which I believe to be true. You know, we both want that baby to go home as quickly as possible and as safely as possible. We may not see eye to eye on what that day is like Um, you know, and then I try and show too, we are working as hard as we can, you know, to get the baby home. But, you know, as we all know, it's actually not up to us at all, totally up to the baby, you know, it's, it's the smallest one in the room gets to call the shots. So I try and do that. And for the most part, it usually works pretty well. But it can be challenging. The book

Daphna: 25:23

does describe a few times, you know what this this chasm we have between us and the parents, no matter how empathic we are, and how good we are at explaining things. And in that story, specifically, I remember you detail, kind of the informed consent for the exchange transfusion, which is separate than the parent we talked about. But we've all been there, we just we give all this information about all of the awful things that are going potentially to happen. And then we say to the parents, and you talk about this. And then we ask for their permission to do these things that we have recommended. And I you know, there's so many times where, you know, we do that, and I'm surprised and the parents say Yes, right? When we tell them all these things can happen. And they, and they say yes. And then sometimes it seems like we asked for things that are quite, we don't see as noxious really, at all. And we have parents who who say no. And you described it as is, you know, do we do the important we have to do the informed consent, obviously. But as almost an unburdening of ourselves, it seems unfair to place that burden on onto families. And I hope you'll talk a little bit about that.

Benjamin Rattray: 26:41

Yeah, I mean, I think that that is the struggle, because you know, with informed consent, you want to give all the information until you feel like you have to give those details. But But like you said, you know, it doesn't seem fair, you know, for example, the decision to you know, for therapeutic hypothermia or for an exchange transfusion, it's something that we spend years and years and years reading all the research papers, and struggling through and then, you know, you get sleep deprived parents in the middle of the night, who essentially have to consent to this over, you know, really a short period of time, you know, maybe 1015 minutes. And sometimes Time is of the essence, you know, so for example, with the exchange transfusion, you can't give them all the information and say, I'll check back with you in a couple of days or a week, after you have time to digest this information. So I think it does. You know, there's, there's a lot of trust, you know, that people have to place in us. And that makes our responsibility huge, and it makes our job very heavy, because, you know, we try and do our best to provide parents with all the information. But we also need that trust, and we're asking them to put their trust in us to do our our very best, you know, we're humans. But we are going to do everything we can to make the right decision and use all the information we have to do that. But I think what I was trying to communicate in that, in that story in that moment was it feels really unfair.

Ben: 28:13

So I guess this this is leading me to my next topic, next question, because we are talking about the pressure under which parents are doing these processes. And, and indirectly, I think you don't really mention this topic head on in the book, but it's, it's interspersed throughout. And that's the that's the topic of burnout. And there's many instances in the book where you for the people who are going through the same things you did these, these, these words resonate. And to me, the one that that impacted me the most was when you describe the parallel between the life of a neonatologist and the life of the sniper right when, when for I'm going to try to to read quickly the paragraph, because you compare the life of this, this servicemen and and the life of a neonatologist and you say I thought about the ways in which we were similar. I too, worked countless hours, pushed my body past its natural limits, felt the sickening nausea of sleep deprivation. I too trained in a hierarchical system and worked for the betterment of other people. Yet, I knew that we shared little, the sniper was willing to put his life on the line in ways I couldn't fathom to hike behind enemy lines, risk capture torture, my separation from my family only ever lasted 30 hours while his last days, two weeks. At the end of my training, my hours would improve and my pay would increase while little would change for him. Still, the wet and the cold and the heavy pack. I knew that it was these truths which separated us and which afforded him a better brother. And and this is the part of the quote that really got to me. You then say I would remain alone, looking in from the outside subconsciously drawn towards someone who would make a real sacrifice. I stood there looking at him as his baby slipped away, and I couldn't do anything to help. And I was devastated. To be honest with you. I like closed, I closed the book took about like, I need a break right now. That's that that's very true. And you don't I'm a little bit upset at you because you sort of dismissed your role. And it's like, Come on this is this is terrifying what you're describing without belittling what the sniper is going through. But this is awful. So I'm wondering why why haven't you? Why aren't you addressing that more head on in the book?

Benjamin Rattray: 30:44

Yeah, so? Yeah, that's, that's a great question. I mean, I think, I think for me standing there looking at all these men in their uniforms. You know, I felt like they had a cohesiveness together, you know, that we don't always have in the medical community. I think that we often don't talk. And when we do, it's often maybe dark humor, or, you know, maybe that tiny acknowledgment like, Hey, you had a rough night. And that's, that's really it, I think, for us. And I think that we really pride ourselves on having very strong protective walls around us. I think that's ingrained in the training, that we need to not talk about these things, you know, when you when you do mortality and morbidity report, you don't talk about these things. You know, really what you talk about is, did you add, you know, an antifungal to the kid who had that, you know, should you or should you have not done that? You know, did? Did you miss the first sign on an x ray, you know, you're really going to talk about the medical management, nobody in the room is going to bring up, you know, wow, that that must have been a difficult experience.

Ben: 32:02

So happy. I'm so happy. You mentioned that. Because early in the book, you do mention the pervasive aspect of our training. And I'm going to quote this as well. It's a short one. But it says, learning to function in high stress on no sleep had taught me to ignore the voice to disconnect to disconnect emotions, and focus on what had to be done. And it sounds great, because it makes you feel like it makes you sound like Superman's like, Yeah, I'm just going to get it done. But it is exactly, I think, what leads to the feeling you're describing later on in the book where you say, I'm remaining alone. And and that's it. I'm isolated. And and there's nobody there to support you from an emotional standpoint. So I'm curious to hear your thoughts as well on on how the pervasiveness of our training really leads us to where we are today where doctors are burning out at very high rates.

Benjamin Rattray: 32:52

Yeah, so actually, just recently, I read a book by a neurosurgeon, called Dr. Joseph Stern. And it's called grief connects us. And it's the story of his sister who died from leukemia, as well as a number of interviews that he has with different patients, and physicians. And he talks about the concept of emotional agility, especially in neurosurgery. But really, in medicine as a whole, which is kind of to your point, there are times when you need to just do what you need to do, you know, you need to have that separation, so that you can technically put on in the breathing tube, or in his case, remove the tumor. And you need to have some ability to do that without becoming overly emotional, you know, I think about when I'm trying to get a breathing tube in and I see the dad off to the side, you know, and the moms crying, I can't think right then about what it's going to be like for them to lose a child, if I don't get the breathing to bed, that's the time where I need everything around me to go black and dim. And I tune out the noise. And I just focus on putting that breathing tube in. But the concept of emotional agility is you don't stay in that space, you know, so after the breathing tube is in, you can then be agile enough to then be empathetic with the parents and to talk with them. And that's kind of, you know, actually have a blog post called go left to go. Right. And it's essentially, there's really counterintuitive principle, which is that we need to lean in, you know, if we can lean in at the right times with patients, we can get energy from them, and we can give them you know, positive support and energy. And so I don't think that the construct, at least that I kind of inherited with training, which is that we build these these really strong walls and we keep out the emotions all the time. I don't think it works. And I think that the book in some ways hopefully communicates that and You know, one of the one of the chapters in the book called Kevin, is the story of a good friend of mine who was in training with me who committed suicide. And I think I don't know why what happened, you know, I didn't see it coming. But, but I suspect that a lot of the things that we're talking about right now we're, we're contributing factors. Right.

Daphna: 35:26

To that, to that point. I, for example, when we talk about the emotional toll and burden and how does how's the system, sometimes working against us? You once wrote, I receive undue praise for good outcomes and criticism for things that I can't control. And that was really talking about how many successes you'd seen come and go in the NICU. But those aren't, those aren't the ones, you know, that we think about that we applaud ourselves for. And maybe we shouldn't, because, you know, sometimes babies get better in spite of us with that because of us. But that no matter how, you know, when things go, when the outcome is not what everyone had hoped for, we carry that as a burden, even if we had done everything, right. In picking in a baby, where you picked an antibiotic choice, and you said I, you know, I was just waiting at all for the next few days to see was it the right choice or the wrong choice as if that made the outcome any different, but emotionally, it feels different?

Benjamin Rattray: 36:36

Right, you know, and in that case, those are the antibiotics that I think 99 plus percent of us would have started, I mean, that's what we all do. So even, even if the bacteria was resistant to those antibiotics, I would have, I mean, I would have felt the burden, and I would have felt guilty. Even though, you know, from a purely medical standpoint, it was the decision that we would all make.

Daphna: 37:04

I really felt. So again, you talked about so many components of being a doctor, but I really felt seen. When you know, you talk about those times, where you have to make the transition, right? Where you're anticipating night call and you can't fully you know, connect with your daughters, because you're on your way tonight call or you're leaving a brutal call, and you have to get back in with with your family. And maybe I can talk about some quotes there each day, I will come home and set my messenger bag in the mudroom. tell my family that my day was fine. And feel the privilege of being part of those lives. There times where you say I love my job. And then other times I felt intoxicated, as the weight of responsibility slid from my back the grief and heartache temporarily left behind when you're leaving for vacation. And then I think the one that probably happens every single day for us, the sun dipped low on the horizon, and I drove home distracted, worrying about my daughter wondering about dinner worrying about Sarah, a patient. And whether I needed to mow the lawn on my next day off such strange, irreverent neuronal search, circuitry bouncing among life and death and the selfishly mundane all in the space of a minute. And that that was useful for me, I feel like that is what my brain is doing all all of the time, whether I'm at home or at work or in the car or trying to sleep. And so maybe tell us, you know, how how do you find, you know, the work life balance?

Benjamin Rattray: 38:38

Yeah, that's a great question. And I feel like with, you know, when you have kids in your house to you, your transitional times are much shorter. I mean, really, they're pretty. Right, exactly. non existent. I mean, you have, you know, your commute home. And that's really it. You know, because when you walk in the door, you very quickly have had to completely shift. And so I think that is, you know, one of the more difficult things. And, you know, I think my wife really understands that, you know, if I walk in the door, and she says How was your day? And I say not so great. She knows, you know, just from that, okay, it was a really rough day. And, you know, she gives me a lot of grace. And you know, we kind of go on and if I walk in the door, and I say yeah, it was fine, like, no big deal. You know, she knows immediately. Okay, that's, that's true. It was a really great day. And you know, sometimes at the dinner table, I'll share you know, if we have a baby went home or something really good happens. kind of share that with the kids a little bit. But you know, it's tough because the kids really hear everything. So, you know, more recently, I think. My wife said, you know, how's your day and I said, That's so great, not realizing that one of the kids was right there. And one of the kids said did a baby die? Like, how is it that my kids, you know, realize that that's a possibility and know about that? And I don't know if that really answers your question, but I guess what I'm trying to communicate is it's very messy. And, you know, I don't do a great job. You know, some of the time, like, I'll come home, and I'll, I'll snap, you know, and then a little later on, you know, I have to apologize and say, Look, I'm really sorry. I didn't want to tell you, but it was a rough day. And I just need to, you know, sort of decompress a little more, I think. So I think it's pretty difficult.

Ben: 40:41

So many things to talk about. I, I. I feel the same. Number one, I think the second book is there, right? I mean, the the credit of the spouses and the loved ones. I mean, where to begin? I know. I mean, I've said this on the podcast, my wife has developed the sixth sense now. I think, just with my tone of voice, she can tell pretty much exactly what happened in the NICU. And her ability to provide the space needed, depending on what happened is something that I'm very thankful for. And yes, my daughter to knows that babies can die. And sometimes I'm wondering if that's not such a bad thing, because it makes her appreciative of right. I mean, not everything in the world is rosy and, and bad things happen to people. And, and she's, I think she's a more compassionate human being because of it. Sometimes it leads to funny situation, when, if we're saying that somebody is not feeling too well, my daughter will say, Do you think she'll need an MRI? But that's my guess, let that leads me to my to my question where you mentioned this at the end of the book, and I hope that that it is okay for me to say, but among the last sentences of the book, you, you say this, and I'm going to put it out of context, and it doesn't matter. But you said I had the sensation of coming home, to find that everything changed, yet, the only thing changed, that was me. And, and that was very powerful. For me to read, just because the NICU is a place that does carve you, right, it carves you in ways that you can't anticipate. And I do this mental exercise very often to sort of look back on my life and say, Where was I? Where am I today? And am I okay with the direction that things are, are taking. Because the NICU can make you more cynical, like you said, like, sometimes you are more irritable. And that's my that's I guess, the love hate relationship we have with the place is that it's a magical place where we can save most babies. But on the other hand, it does change you profoundly. And I'm wondering, what is your take on how the NICU has changed UN? And what's the net overall effect? Is it net positive? Do you think it would be negative in your opinion? And can you tell us a little bit more about that?

Benjamin Rattray: 42:55

Yeah, I mean, it's an interesting point, because, you know, sometimes I find myself surrounded by a group of people who are not in medicine. And sometimes it's a very isolating experience, you know, because people are interested in what we do. But, you know, sometimes somebody will say, Well, what do you do, and I sort of start to tell them, and they say, Oh, that's great, you get to work with all the cute little babies. And, you know, you think that's, that's not quite how it feels to me. You know, I mean, some of those babies are really cute, and we, we love them, but unfortunately, they're in the NICU for a reason. And so I think that we really do change over time. What I'd like to think, is that we change in depth over time. Because we see all of these, these nuances. I feel like, you know, there's there's sort of no, no hard edges in a way because there's always a range of emotion, there's always a different level of medical complexity, and emotional complexity, and things that maybe I took for granted before I don't take for granted now. So I feel like over time, I'm a more thankful person for the things that I have in my life and thankful for free, healthy children. You know, I remember even in pediatric residency, giving one of the kids a bath, you know, it's sort of like feeling their back and feeling, you know, their kidneys, okay, you know, kidney tumor. And, you know, and, you know, it's, I think it's sort of infuses you with this gratefulness. And this passion, you know, for what we do to strive to be better, and not only better medically, but better at connecting with the parents better at emotionally supporting the team around us, you know, that the nurses around us, everybody else. And so what I what I would hope is that, you know, as you were saying, Ben, as you look back sort of in the trajectory of your life, how are you changing? I'd like to think that over time sort of going going through for connecting in new ways, I mean, I feel like the way that I connect with parents right now is really different than when the way that I connected five years ago, you know, when at that point, I was trying to just be very professional, and just give absolutely the facts and the medical opinion. And I didn't really allow as much space for that interaction. So I feel like over time, hopefully I'm, I'm communicating more with more empathy, and actually getting closer to parents into patients over time.

Ben: 45:35

So that leads me to one more question. Definitely, that's okay. Because I wanted to talk about that you mentioned it early on in the interview, and I was holding back, but let's talk about faith. Because in my opinion, the NICU is the best place to just wreck somebody's faith to the ground. Yeah. Leave it in pieces, and just stomp on it just for good measure. So through the book, you mentioned this, this, this, this passage where you're going to this church group, I guess, if if I'm if I'm portraying this correctly, if not, let me know. But basically, where you guys are discussing things and and you remember all your patients, right? And it it, I guess, you're not saying the word, but anger just like makes you question everything. The pastor is saying, and you're inquisitive, and you're just, you're just going to town. But then you resolve this issue in one sentence where you do say that, and I quote, you said he revealed a God who could redeem anything, but who did not cause the underlying tragedy. And and you move on from there. And, and I was not satisfied. And so I'm wondering, because I was reading this, and I'm like, There's no way that this that it is this simple, maybe it is, but I want you to tell us more about how do you reconcile what we see on a daily basis, right? I mean, let's, let's be a bit raw here. But when a mother is pleading God to save her baby, and the baby passes away, regardless, how do you reconcile these stories, as you say, like, the girl with a bandana who was like, the, I'm assuming was a cancer patient? To the concept of faith? And, and, and how, yeah, how do you reconcile that? I'm curious to hear.

Benjamin Rattray: 47:20

Yeah, I think you're right. I mean, you know, for me, it's been Nikki really did exactly what you just described with my faith. You know, I had a time where, you know, I walked into church, like, I just couldn't sit there anymore. Because, you know, you come off that night call, we're just like you described, you see something that's just totally gut wrenching? And so really, the question is, you know, how do you reconcile that good god with the suffering that we see? And that's a question that, you know, obviously, there are books and books and books written about that topic. And I didn't, I didn't want to set out to resolve that, that question, per se. But that being said, it was also a question that I have to wrestle with. And so I think that, that, you know, this gets into a very nuanced, complicated question, which is, you know, does God have sovereignty over what happens in the world does he have control over what happens in the world, and if he does, then that puts us in a very difficult position, because we see the suffering. But But what I do believe is that God does not cause these things, he doesn't make them happen. I think that we live in a messed up world, a broken world, a world where, you know, these natural tragedies happen, you know, whether it's, it's hurricanes, or sepsis, you name it. And I think that these things happen, but I don't think that God, you know, sort of points the finger and says, I'm gonna make this happen for a reason, you know, and then there is actually a book called, everything happens for a reason, and other lies I have believed, which is a phenomenal book, where, you know, she really kind of answers this question, you know, she, she has cancer. And people tell her, you know, I think I gave you cancer, so that you could, you know, appreciate your life. Right, so that you could appreciate your, your child more. And, you know, at least you have, you know, some time that live, I mean, at least it's not like pancreatic cancer, you know, people try and sort of make her feel better with these things. And I think my my point and writing that paragraph was my own personal belief that I don't believe that God gives us these things to teach us a lesson. But I do believe that we live in this broken world where really bad things can happen. And I believe that God is with us, and not necessarily in a way that you know, you can snap his fingers and fix everything. Not to say that that couldn't happen, but I don't See, you know, us living in a world where that happens, you know, every single day all day. So I don't I don't know if that answers your question, but that's it's definitely

Ben: 50:10

it does. It does. Because I mean, at the end of the day number one I wanted to commend you on on breaching the subject, right. I mean, I was in awe too, just when the when the topic came up and like, holy moly, that is very brave. Because it's, it feels very personal, right. I mean, this is not everything for people who are listening. The faith of the neonatologist is something that we don't like to talk about. And we all and I think the reason why your answer Does, does answer the question, but it doesn't answer my question, and they won't answer darkness. Question is because our vision of the role of of divinity and God in the world is different for everybody. And there's no right or wrong answer. So, yeah, again, I think this is this is tremendous that, even if, if I if I, if the book can can leave you wondering as to exactly what is your thought process, and you've explained that, but I think it is, it is something that we all have to wrestle with, and I think it's honest to say that we should tackle, tackle it head on, just like you did just just as you described in the book. So yeah, thank you for that.

Daphna: 51:15

Well, I found it especially valuable. You know, even I think, even if you're not a person of faith, that many of our patients are struggling with that. And aside from the guilt that moms carry about, say prematurity and what role do they feel they played? Even if we know for a fact that there was none? They? Some of those religious undertones? are, you know, did? Did I deserve this? What am I supposed to learn from this? And it really is hard for them in the moment to sit with that. And I think at a minimum, like you said, as we're growing emotionally, we're able to get closer to parents, it's so it's okay to broach the subject with them, even if our cultures or religions are different, or even if we don't believe the same thing that you can, you can understand what these extra weights that people people carry with them. And so I thought that was particularly valuable. Especially, I'd say, for the trainees who listen to us that's, that's what's so valuable about the book is because you broach a number of difficult subjects. And I think it allows people to say, oh, it's not just me, I, I'm thinking about those things, too. And I'm questioning those things, too. And I don't understand why. And I don't understand what my role is in in dealing with this, you know, chaotic universe. I think you especially touched on that, when you talked about cooling or prolonged resuscitations, and saying, Did I intervene? You know, did I do the right did was intervening, the right choice or the wrong choice. And again, regardless of what you believe, that's something that I think affects all neonatologists. So

Benjamin Rattray: 53:12

yeah, and I really, I mean, I really appreciate you saying that, because it is intensely personal. And it's, it's difficult to put these things out into the world. But at the same token, I find it unavoidable. You know, I had a baby that we were withdrawing support on who had terrible HIV. And I was sitting with the mom. And she looked at me, and she said, why did this happen to me? I am a good person. Why? And I've, and I follow God, why did God do this to me? And so I feel like these questions really are unavoidable, you know, they're difficult. And it's, you know, and I don't think that there's, you know, sort of a hashtag line that you can just come up with, you know, I think that it really is very complicated. And like you said, it's very personal, too. But, but I appreciate what you said. And I do think that, you know, it's something that it's unavoidable, you know, both for ourselves and for our patients.

Ben: 54:10

We're coming close to the end of the hour. So I would like to touch on another subject, I guess, that I wanted to ask you about. So that the book is is broken down into three parts, as we said, you start with training, young attending and becoming and it's and it's, I guess, chronological in what in your evolution as a physician. And my take on the organization of the book is that, I think it's, it's how, as a physician you've grown to tolerate and manage uncertainty, right. You mentioned the word uncertainty many times throughout the book. And and I feel like I related to how the overwhelmingness of the NICU gets less and less overwhelming as you become older, and more senior and more experienced. And so first of all, I'm wondering if this is a an accurate or or, or a possible interpretation of the book and then I would like to know from you is, is it time only that gets you to this point of, of calmness where you can tolerate uncertainty and a much better way as you become older? Or is it? Or is it something else? Or is it a combination of things?

Daphna: 55:21

That was my question?

Benjamin Rattray: 55:25

Yeah, I think it's a mixture of things. I mean, I think one of those aspects is time, you know, you need time and maturity to kind of work through, you know, some of these things. And, and that's why I call it becoming too, because, you know, that's, that's the joke, right? I'll never read that book arrived, because this is really, truly a process. And I hope, like when you were saying, when you look back, you know, your trajectory, I hope that when it look, you know, back, like saying, you know, five and 20 years, hopefully, I will have matured and grown, you know, quite a bit beyond where I am now. But I think, you know, one one part of his time, but I think another part of it is, you know, being open to it, you know, there, there's so many great books, that we can read about other people's experiences. I think that there are practices that we can do, you know, for me, it's writing, I was recently talking to somebody in Colorado, who is a visual artist. And so she has some amazing, you know, visual art, which is all related to the NICU. So I think part of it, you know, might be tapping into some of these things. You know, you have a gift of interviewing people bringing out stories, bringing the NICU community together, in ways that not everybody can do. And so I think, I think it's not only time, you know, but I think we have to engage in some of these other activities as well, that are, you know, artistic or introspective. That will also, you know, defend us.

Daphna: 56:56

Yeah, I think you called uncertainty, the shadow land of greys. And I think, you know, I was going to ask you, what is the tip you have for, for, you know, trainees are really all of us, since we're all still stress, still struggle everyday struggling with uncertainty. And I think, I think you describe it, and just like you said, you just sit with it, and know that it will persist with us. And I know, there's some times where you had another quote, trying to determine the course she was on was like reading tea leaves. And sometimes it feels like that, and you just, you plow forward, and you do the differential and you sit with the uncertainty. So I really appreciated that you you express that through your writing. And, and to your point about finding these outlets. I'm wondering, you know, how do you think Narrative Medicine, you know, can help physicians, and I'm sure we have some listeners who say like, that's just not for me, that's not my style, but, but I think it's important that we'll hear about it, because I think even you know, maybe we can broaden Narrative Medicine to include our patients more. And so I'm wondering how you think that the arts, you know, fit in with medicine?

Benjamin Rattray: 58:13

Yeah, you know, it's interesting, because when I was in training, I had no interest in anything outside of immediate patient care. You never say no interest in business, no interest in administration. And if I saw what I was doing now, I probably would have, you know, felt like it was really a very kind of soft, sort of thing to be doing. Right. I mean, I think I would have been exceptionally critical to be honest. It's sort of funny to have landed at this place where now I've studied business, and see the importance of, you know, good leadership, good administration. And I think, you know, when it comes to Narrative Medicine, I certainly understand a lot of people do not like to write a letter days, I'm not entirely convinced that I like to write either it can be a very painful process. But But I think that it allows us to have introspection, it allows us to process things and I believe to that reading other people's experiences can be really powerful. There's a book called in shock by Raina outage. Yeah, I mean, you know, absolutely phenomenal book. Really, I think it should be required reading for everybody, you know, really, to be honest, but especially people in medicine. And so if you don't like to write, I think that's okay. But, but I think reading these books like this are really important. And if, if you're someone that you know, is a visual artist, or plays music, or you know, I think that there are things that we can do, and certainly incorporating you know, patients and parents is really important too. But I think it's important that we do it things other than just the pure bedside management, of course. that time management is paramount that comes first. But we have to be people too. And we have to kind of work through our experiences not only by yourselves, but with each other.

Ben: 1:00:12

I have one more question.

Daphna: 1:00:14

You couldn't help yourself.

Ben: 1:00:17

And it may be, it may be you, we're definitely gonna go over time, I don't care. I wanted to ask you about the role of your family in the context of your career, we touched on your kids and your wife already. But it's interesting that as podcasters, we've asked many of our of our guests, how do we build strong boundaries, so that we can really separate work and, and home and have work life balance, right. And in the book, I'm not sure if this is purposeful, but it seems that there are no boundaries, meaning you really make a point to describe how things flow in and out from both from both realms. And, and your left. I mean, at least I'm left wondering, is this the way to do it, meaning not to try to build artificial boundaries and just let the emotions dissipate between the two spheres? Or do you think this is a a fault of yours, where you say, Maybe I shouldn't do that I shouldn't expose my family to the stressors. And so I'm yet so that I guess, it's my question, is this intentional? Where you say, I'm just going to let this be a continuum? And or are you describing this as as a warning sign to others saying, Be careful what translates back and forth?

Benjamin Rattray: 1:01:37

Yeah, I believe that there has to be a merging of the two. And, you know, so my wife was my first reader for all of these stories. She's an amazing editor. You know, not by profession, but she's a great reader, and a great editor. And so she read all of these stories, and, you know, sometimes she would read a story and shake her head and say, This is not not really going to work, you know, and I would spend another three or four months, you know, rewriting the chapter, and, but she was, she was part of all of this, and she's been a part of this whole story, you know, all the way from medical school. You know, I remember her yelling at the neighbors who were being loud. You know, late one night, when I had to take boards the next day, you noticed, she leaves late, she goes, I can't remember, she leaned out the window, went outside, and, you know, pull them to be quiet, because, you know, I have boards. Here, she moved across the country with me, I mean, she, she has been behind every single part of this. And every time that I have tried to construct a wall to, you know, to keep her from knowing that I was upset about something, or stressed about something has totally backfired for me. You know, I've never been able to successfully do that. And I feel like our marriage has really deepened over the years, because she is such an integral part of all of this. And so to answer your question, I think, for me, at least, you know, and every marriage is different, and every person is different. I think we have to be careful not to just dump on our spouse, you know, I mean, if, if I walk in the door and just sort of, you know, dump everything, right, right on her when she's trying to deal with, you know, all the all the stressors that she's dealing with in her day. I don't think that that would work well. But I think that, you know, for a marriage to really work and to be strong and support each other. I think you really do have to have these conversations and and be each other's support. You know, I think that's an important right answer.

Daphna: 1:03:39

Yeah, boundaries are funny at at my house, I must share, if you will, maybe more than the two of you. And then I started to notice that every time my daughter was playing with her baby doll, she was basically running an ICU. So the babies are always sick. Right? So but it was a reminder to me that maybe I did have to share some of the successes about the babies who were who were going home, because I was seeing myself reflected in her. And I thought was actually a pretty valuable lesson for me. But I think like you said, they'll they'll know whether we had a good day or bad day, whether or not we tell them. And one of the valuable things I think you taught us all today is that sometimes we do snap and you you said, I come back and I have to apologize and say, you know, it wasn't in the right, right mind frame. And I think that's how our relationships with our families get better. And that's how we teach our children that, you know, work is hard, and we can't leave it there. And that when we make mistakes, we apologize for them. And so I think, even through this interview, this has been very valuable for me personally, and hopefully for our listeners. And I loved what you talked about the shared experience and connect Didn't notice and I hope people will take up the opportunity to read your book because like I said, I felt I felt seen. I think parents feel seen I think our our teachers and our nurses will feel seen by by reading your book. And I think knowing that other people are going through what we're going through, helps lighten the load a little bit. So I'm just so grateful for for you taking the time to do that and to be with us, you know, today.

Benjamin Rattray: 1:05:29

Thanks. Yeah. Thanks so much for having me on.

Ben: 1:05:32

Yeah, congratulations on the book. Again. It's called when all becomes new, a doctor's stories of life, love and loss. Ben, it was it was a pleasure. I mean, I wish we could go on for another couple of hours. We probably could was tremendous. Thank you so very much. Yeah.

Benjamin Rattray: 1:05:48

Thank you so much.

Ben: 1:05:50

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 podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address, Nicu podcast@gmail.com. You can also message the show on Instagram or Twitter, at NICU podcast. 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