#423 - 🏖️ [COOL TOPICS] - Should Neonatology Break Free from Pediatrics? (ft. Dr. Satyan Lakshminrusimha)

Dr. Satyan Lakshminrusimha, Chair of Pediatrics and Pediatrician in Chief at UC Davis Children’s Hospital, makes a compelling case for rebranding and restructuring neonatology as a field. He argues for adopting the title of neonatal critical care physician, addresses the stark disparity between NICU revenue generation and neonatologist compensation, and outlines a step by step resuscitation framework for the field, from restoring professional identity to establishing a dedicated neonatal residency pathway and ultimately recognizing neonatology as its own independent department.

Transcript

Ben Courchia MD (00:00.814) Hello everybody. Welcome back to the Incubator Podcast, live at the Cool Topics in Neonatology Conference in San Diego. We are joined in the booth this afternoon by our good friend — and I'm so proud to be able to say our good friend — Dr. Satyan Lakshminrusimha. Satyan, welcome back to the show.

Dr. Satyan Lakshminrusimha (00:16.376) Thank you, Ben. You're the only person who pronounces —

Daphna Yasova Barbeau MD (00:20.27) I practiced a lot.

Ben Courchia MD (00:21.646) I sat down and — okay, I'll tell you how I remember your last name. The last part is "Simha," which in Hebrew means "joy." And every time I talk to you, it is a joy.

Daphna Yasova Barbeau MD (00:33.774) Hmm.

Dr. Satyan Lakshminrusimha (00:34.19) That feeling is mutual.

Ben Courchia MD (00:36.526) Thank you.

Daphna Yasova Barbeau MD (00:37.926) And then the rest just rolls off the tongue once you've got that part. But we do struggle with names sometimes — and names are really important. I'm always reminding the team: learn the baby's name, learn the family's surname. Names matter deeply to families. But I've gotten off track. You're going to tell us how you're going to resuscitate —

Dr. Satyan Lakshminrusimha (00:41.006) That's a good one.

Daphna Yasova Barbeau MD (01:05.432) — compensation in neonatology. You've outlined a plan to fix things.

Dr. Satyan Lakshminrusimha (01:09.678) Yes. I have spent my research career working on neonatal resuscitation. This is a slight detour — instead of resuscitating neonates, I want to talk about resuscitating neonatology as a field. And rather than calling it neonatology, I would much rather call it neonatal critical care. I want to thank both of you for changing your introduction and calling yourselves neonatal critical care physicians.

Ben Courchia MD (01:37.71) Which we did not at your request, but after a conversation with you where you highlighted that point. We went back and looked and said, "He's absolutely right." So we changed it. And it's not an easy thing to do — I still need to update the recording for the French podcast. My editors have been reminding me for six months. But we took what you said to heart and we made the change.

Daphna Yasova Barbeau MD (01:58.668) I changed it in French too.

Dr. Satyan Lakshminrusimha (01:47.458) Perfect.

Dr. Satyan Lakshminrusimha (02:04.782) The fact that both of you made that change means so much to me — and for one big reason. Robin and I were talking about it, and you may have heard this earlier. I have a close friend who is a neurosurgeon. When we go to philanthropic meetings together, every parent or layperson who meets him — the moment he introduces himself as a neurosurgeon — they know exactly what he does. They picture someone opening up the brain and operating. They know what a neurosurgeon is. When I say I'm a neonatologist, they say, "What is that?" And I say, "I'm a pediatrician who deals with babies." And every single time —

Daphna Yasova Barbeau MD (02:37.166) It's on TV all the time.

Daphna Yasova Barbeau MD (02:51.458) Yeah.

Dr. Satyan Lakshminrusimha (02:52.142) — they picture me sitting there feeding babies and changing diapers. What they don't realize is that yes, I'm a baby doctor — I know how to change diapers and how to clean meconium, which is not easy. But I also know how to manage meconium aspiration syndrome, how to send a baby to ECMO, how to provide critical care. That's why I want us to stop introducing ourselves as neonatologists and call ourselves neonatal critical care physicians — because that's how the PICU community identifies itself. Their society is called the Society of Critical Care Medicine. Pulmonologists call themselves pulmonary and critical care physicians. We are the only critical care subspecialty that doesn't call itself critical care. And in many health systems, the NICU is the largest ICU. So it's really important that we own that identity, because we have an identity crisis in our field.

Ben Courchia MD (03:59.214) And that segues nicely into one of your slides — my favorite slide in the entire presentation — where you look at collections across departments. When you compare revenue generated by the NICU against other departments, the NICU accounts for about 31% of collections, compared to 12% for cardiology and 18% for the PICU. But when you look at salaries and benefits, you would expect the NICU to be compensated at roughly three times those figures — and instead we are on par with, if not below, the PICU, and essentially equal to cardiology. Despite generating so much revenue for the hospital, that tells a very eloquent story about a serious disparity in compensation. What do you think we should do about it?

Daphna Yasova Barbeau MD (04:19.052) You're making him skip ahead.

Dr. Satyan Lakshminrusimha (04:59.694) We can do a lot, but let's take a step back. The numbers you're citing refer only to physician and provider fees — and that's a small component of total collections. The facility fees the hospital collects are a much larger component, and the NICU is a major source of that revenue. In many children's hospitals, the NICU's administrative and facility fees are what sustain the institution. We recently talked about a topic called "tiny babies and big bills." These 500-gram babies generate substantial costs — yes, they represent a significant investment by society — but the quality of life that results from that investment spans 50, 60, 70 years. The return on investment in neonatal critical care is extraordinarily long-lasting. That's really important. And the second point is that NICUs support many other units in a children's hospital — they are a primary source of revenue, both on the provider side and the facility side.

Ben Courchia MD (06:09.174) And I want to be clear — when we say that the NICU floats other departments, it's not out of jealousy or bitterness. It's to highlight a problem that needs to be addressed. The goal isn't to point fingers at endocrinology or rheumatology. The point is that there is a structural problem where these subspecialties need to become financially self-sustaining, so that the health of the children's hospital as a whole can be sustainable.

Dr. Satyan Lakshminrusimha (06:43.416) You're absolutely right. There are two underlying issues here. One is an ongoing pediatric subspecialist crisis in this country — fellowships are not filling. Neonatology fell below 90% fill rate for the first time in 2024. Pediatric nephrology recently filled somewhere around 38% of its positions. These numbers are very concerning. The margins in neonatology are starting to narrow because of various pressures — Medicare policy changes and others. The answer to the pediatric subspecialist crisis is not increased dependence on neonatology revenue. It's to make policy changes — CPT changes, work RVU reimbursement changes — so that each subspecialty can stand on its own. Pediatric endocrinologists work very hard. General pediatricians work very hard. There is no reason why they should not be paid appropriately enough to be self-sufficient and not financially dependent on other fields.

Daphna Yasova Barbeau MD (07:51.17) That's my favorite slide of yours — showing the compensation of adult subspecialties compared to their pediatric counterparts. You go up the pay scale for all the pediatric subspecialties, and then you start with the adult subspecialties, and the gap is stark.

Dr. Satyan Lakshminrusimha (08:15.438) The classic example is pulmonary critical care. An academic neonatologist generates twice the number of RVUs as an adult pulmonary critical care physician. And yet our salaries are somewhere around 70 to 75% of what an adult critical care physician earns. There is no other explanation except that we take care of smaller patients.

Ben Courchia MD (08:39.086) Which, if you think about it in terms of technology, is like saying the engineers who can make the phone smaller get paid less than the ones who build a bigger phone. In technology, it would be exactly the opposite — miniaturization commands a premium. But in our field, it's inverted.

Dr. Satyan Lakshminrusimha (08:59.758) Someone should illustrate that. Because of all of these things, I am genuinely worried that neonatology — both academic and non-academic — is entering a crisis. I am worried about our pipeline and what's coming. I did my fellowship in the 90s and have been closely following the field for 30 years. And I've been thinking about what has changed — because the babies are the same. I see two major shifts that have affected morale.

The first is what I call "tube thrill" — procedural euphoria. When I was on call, we did 24- and 36-hour shifts. At the end of a call, I was physically exhausted, but mentally energized — I had placed three chest tubes, done five intubations, and watched babies get better. That euphoria, that tube thrill, was real. Now, we have fellows completing their training without ever placing a chest tube or performing an exchange transfusion. You come on call and spend most of your time on the electronic medical record — planning discharges, conducting family meetings. The procedural thrill is gone. That is contributing significantly to burnout.

The second issue is what I call the "Six Cs." Clinical acuity has risen dramatically. Chronicity has increased — we have babies spending their first birthday in the NICU, which is not uncommon. Babies who would have died in the past are surviving, which is wonderful, but they are staying longer and becoming more medically complex. It's increasingly rare to have a straightforward baby with RDS who recovers and goes home — there's almost always a PDA, another complication layered on top. We have also become a highly consultative practice — genetics, infectious disease, and many other specialists are required regularly.

Dr. Satyan Lakshminrusimha (11:12.22) And then there is charting. It has taken the joy out of the NICU. A resident rotating through does not see an enthusiastic neonatologist placing lines and tubes and running resuscitations. They see a neonatologist sitting in front of a computer writing notes. That is not inspiring the next generation to choose this fellowship. And because of the high acuity, service blocks have become shorter — a week or ten days at most — which means the biggest complaint I hear from families is loss of continuity of care. So: clinical acuity increasing, complexity increasing, chronicity increasing, more consultative practice, greater charting burden, and loss of continuity — all of these together are eroding morale in our field.

Daphna Yasova Barbeau MD (12:19.918) You've spoken about loss of morale and declining reimbursement. What is your countdown clock? By when do we have to act before we are in serious trouble?

Dr. Satyan Lakshminrusimha (12:39.606) Yesterday.

Daphna Yasova Barbeau MD (12:41.23) That's true of the climate countdown clock as well.

Dr. Satyan Lakshminrusimha (12:44.238) The crisis is here. We really want our field to thrive, and that's why I want to frame this as a resuscitation. Look at the ninth edition of the NRP textbook — every single step applies to our field right now. We need stabilization. We need increased recognition. Every step of neonatal resuscitation maps onto what our field requires.

Ben Courchia MD (13:16.11) And this matters for the benefit of the next generation. If you're early-career right now, you may actually benefit from the shortage — you will be in high demand. But the generation after that is where the shortage becomes too significant to overcome. If we think today's medical deserts and neonatal deserts are concerning, we haven't seen anything yet.

And frankly — while we talk about this primarily as a US problem, it is already happening in France. The number of labor and delivery units closing in France is appalling. Families now have to relocate near their due date just to be close to a delivery center. And this is France — a well-resourced, developed country. This is going to be a universal problem.

Dr. Satyan Lakshminrusimha (14:16.248) And the issue is compounded by something you've rightly pointed out, Ben — obstetric deserts. What's making things worse right now is that a typical pediatrician graduating from residency is genuinely concerned about attending a delivery alone. The time they spend in the NICU and delivery room during training is so limited that the confidence to manage a delivery room baby has eroded. And I'm not even talking about intubation — intubation is actually the least critical step. They may not know how to provide effective bag-mask ventilation. That is what concerns me most.

Ben Courchia MD (14:56.619) Many centers report that pediatricians are declining to attend deliveries, and I think —

Daphna Yasova Barbeau MD (15:03.015) We have some pediatricians on our team who are not comfortable going.

Ben Courchia MD (15:06.754) And it's not because they're lazy — these are hardworking people. They simply don't feel confident that they can provide the best possible care. And that is a serious concern.

Dr. Satyan Lakshminrusimha (15:16.238) There's an economic angle as well. I was a private pediatrician for three years in Pueblo, Colorado. If I was called to a C-section, I would go, observe, do basic resuscitation if needed, write a note, and drive back. The whole thing could take three hours. If I had spent those same three hours in the clinic, I could have seen twelve patients. Economically, attending a routine delivery is not viable — unless the baby is sick and requires acute medical care.

Ben Courchia MD (15:53.422) So for the people listening for whom this resonates — what do we do? What is the next step?

Daphna Yasova Barbeau MD (16:07.234) What can we do as individuals? Or do we just say, that's for the section to handle, that's for my medical director?

Ben Courchia MD (16:15.896) We want people to feel like they have agency — that they can act, not just say, "I should quit." To me, the exodus of physicians out of medicine is the worst possible outcome of burnout. We need solutions that keep people in the field so we can fix this together, because leaving does not help families.

Dr. Satyan Lakshminrusimha (16:45.186) The solution is not simple, because the problem is deep-rooted. The solution maps onto the neonatal resuscitation algorithm. Our field is in distress. The first step — stabilization — is restoring identity and importance to the field. That is why I want us to be called neonatal critical care physicians. That's what we provide.

Daphna Yasova Barbeau MD (17:15.8) So that's something everyone can do right now — start introducing themselves differently.

Dr. Satyan Lakshminrusimha (17:19.071) Yes — call yourselves neonatal critical care physicians. The second step: just as appropriate ventilation is the most critical intervention in neonatal resuscitation, the most important systemic step right now is appropriate staffing and properly defining clinical FTEs in neonatology. There is no reason a neonatologist should be working significantly more hours than physicians in comparable fields. I really applaud the Women in Neonatology group and the work led by Kerry Macker and Millie —

Ben Courchia MD (17:58.67) Who we've had on the podcast. The INS Toolkit, available on the AAP Section website, is a tremendous resource. We dedicated a full episode to it because it is the practical, actionable guide for what to do next.

Dr. Satyan Lakshminrusimha (18:18.776) Yes — the INS Toolkit is the T-piece resuscitator of the field. Following the recommendations in that toolkit is something every one of us can do, every unit director can implement. These are critically important steps.

Ben Courchia MD (18:24.462) Absolutely.

Daphna Yasova Barbeau MD (18:37.002) For anyone who wants to listen to that episode, we had them on —

Ben Courchia MD (18:41.664) Episode 292 — Women in Neonatology staffing practices. Satyan, thank you so much for dropping by.

Dr. Satyan Lakshminrusimha (18:51.244) One more thing.

Daphna Yasova Barbeau MD (18:52.814) You have as much time as you want. Don't let him rush you. You didn't finish the resuscitation algorithm.

Dr. Satyan Lakshminrusimha (18:58.542) If bag-mask ventilation doesn't work and the heart rate doesn't come up — what do you do?

Ben Courchia MD (19:04.652) We intubate. And then chest compressions.

Dr. Satyan Lakshminrusimha (19:09.74) So if the measures in the INS Toolkit aren't sufficient, chest compressions are required. And that means establishing a separate neonatal residency. We cannot depend on pediatric residents to staff our units if ACGME is reducing neonatal exposure in pediatric training. If residents only rotate through for four to six weeks, I don't have time to inspire them to choose neonatology. We need a direct pathway from medical school into neonatal residency. If pediatric neurology can have its own residency track, I see no reason neonatology cannot do the same.

Ben Courchia MD (19:49.034) And it could still integrate pediatrics — the first 18 months of training could be in general pediatrics, and then —

Daphna Yasova Barbeau MD (20:00.258) Like child neurology.

Dr. Satyan Lakshminrusimha (20:02.188) Exactly — that is the chest compression piece.

Daphna Yasova Barbeau MD (20:06.486) Are we there? Do we need to start chest compressions now?

Dr. Satyan Lakshminrusimha (20:10.312) This should have happened yesterday. So let's go to the next step — if chest compressions don't work, what comes next?

Ben Courchia MD (20:15.85) Epinephrine.

Daphna Yasova Barbeau MD (20:19.345) Yeah. And for the field —

Dr. Satyan Lakshminrusimha (20:21.56) Yes.

Ben Courchia MD (20:22.09) Epinephrine for the field means — Dr. Satyan is going to tell us we should be our own department.

Daphna Yasova Barbeau MD (20:23.902) Vascular access.

Dr. Satyan Lakshminrusimha (20:29.774) Yes — not only in academic settings, but in non-academic ones as well.

Ben Courchia MD (20:34.552) Just as neurosurgery is its own department, and ENT has evolved into the department of otolaryngology — we should be the department of neonatology, independent of the department of pediatrics.

Daphna Yasova Barbeau MD (20:40.248) There's precedent.

Dr. Satyan Lakshminrusimha (20:46.478) And the number of neonatologists in this country far exceeds any of the surgical subspecialties you mentioned. We are the largest subspecialty in pediatrics. Just as children are not small adults, neonates are not small children — and premature babies are not small term babies. They are each distinct populations requiring dedicated subspecialties. There was significant resistance when pediatrics split from internal medicine — "Why do you need a separate field for children?" — and now we know exactly how important that was. We are reaching the same inflection point with neonatology.

Ben Courchia MD (21:22.894) And we're already seeing subspecialization within neonatology — small baby care, late preterm care, neonatal hemodynamics, neonatal nephrology, neonatal neurodevelopment. Being a subspecialty of pediatrics may actually be limiting our ability to grow into all of that.

Daphna Yasova Barbeau MD (21:38.232) A subspecialty of a subspecialty.

Dr. Satyan Lakshminrusimha (21:49.782) Exactly. And Ben, you're becoming a neonatal cardiologist.

Ben Courchia MD (21:52.75) Which only underscores the complexity of our patients — gestational age, comorbidities, weight, pulmonary status, hemodynamics. The clinical complexity is at an all-time high.

Dr. Satyan Lakshminrusimha (22:11.126) Here's a classic example: you call a hematology-oncology consultant for a neonate with thrombocytopenia. A typical hematologist-oncologist spends the majority of their time in oncology care for older children and is often uncomfortable evaluating neonatal thrombocytopenia, which has an entirely different differential. Subspecialization within neonatology — neurology, cardiology, hematology, and more — is genuinely necessary. We are approaching a stage where neonatology can be a separate department with its own internal subspecialties. What happened to pediatrics in the 1960s is overdue — and it needs to happen in neonatology now.

Ben Courchia MD (22:57.558) Just as pediatrics once separated from obstetrics, and neurology from psychiatry — there is a healthy and natural evolution here. I'm just a little nervous to close out the show. Thank you so much for dropping by.

Daphna Yasova Barbeau MD (23:09.624) There's precedent.

Dr. Satyan Lakshminrusimha (23:12.268) That's a good framing — I like it.

Daphna Yasova Barbeau MD (23:18.068) He's closing his computer.

Dr. Satyan Lakshminrusimha (23:21.518) Thank you for having me. This is a topic I feel very passionate about.

Daphna Yasova Barbeau MD (23:26.688) We can tell. And I think people should recognize how much you have dedicated yourself to changing the future for all of us in this field.

Ben Courchia MD (23:38.508) Head over to the Incubator Podcast YouTube channel and search Dr. Satyan — he gave a Delphi talk on this subject in September 2024. It's a great watch. Eighteen minutes.

Daphna Yasova Barbeau MD (23:49.998) Go watch it.

Dr. Satyan Lakshminrusimha (23:50.648) Thank you both for amplifying the voice of neonatology and neonatal critical care.

Daphna Yasova Barbeau MD (23:55.054) Bye everyone.

Dr. Satyan Lakshminrusimha (23:58.2) Thank you.