#447 - 📑 Journal Club - The Complete Episode from June 13th 2026

Phototherapy duration, jaundice and UTIs, extended CPAP, and The Pitt. A full week on the Incubator Journal Club.

Ben opens with a nationwide Swedish cohort study from JAMA Network Open examining phototherapy duration in nearly 5,000 very preterm infants. Longer phototherapy was not significantly associated with late neonatal mortality, but six to seven days was associated with significantly higher rates of severe neonatal morbidity. With 95% of the cohort receiving phototherapy, Ben and Daphna question how much evidence actually supports the near-universal practice.

Daphna follows with a retrospective study from Istanbul showing that 31% of term and near-term neonates hospitalized for unexplained hyperbilirubinemia had culture-proven UTIs, with pathological renal ultrasound findings independently associated with a 4.6-fold increased odds of UTI.

Ben then reviews the extended CPAP secondary analysis by Mamidi and McEvoy, showing that two additional weeks of bubble CPAP reduced intermittent hypoxemia episodes from 151.7 to 57.6 compared to discontinued CPAP.

Daphna closes with the NEOASP five-day UTI treatment guideline from Nationwide Children's Hospital, where a structured stewardship approach yielded a 1% failure rate.

Ben and Eli close the week reflecting on The Pitt and what it reveals about the broken realities of American healthcare.

Transcript

[00:00] Ben Courchia, MD: Hello everybody, welcome back to The Incubator Podcast. We're back today for an episode of Journal Club. Daphna, good morning. How are you?

[00:08] Daphna Barbeau: I'm doing so well. I was actually, just —

[00:11] Ben Courchia, MD: Liar.

[00:14] Daphna Barbeau: Okay, fine. I've been disgruntled about a number of logistical things in the last week, so that's true. God, you don't have to air all of our dirty laundry.

[00:18] Ben Courchia, MD: You're grumpy today.

[00:25] Ben Courchia, MD: There we go. We come as we are.

[00:32] Daphna Barbeau: All right, sure. I mean, don't we all have those small logistical things — you feel like they stack up over the course of a week and you're like, gosh, I just can't do anything today. But here we are. We're going to do Journal Club regardless.

[00:46] Ben Courchia, MD: I found that this actually happens when you're quite busy. When you get quite busy, if things go well, you manage. But as soon as something doesn't go quite well, the toll it takes is exponentially higher than it truly is. Sometimes you deal with things that are not objectively a big deal, but because you're tired and managing a million different things, that small thing is going to be like the grain of sand in the watch mechanism — it's going to throw the whole thing off.

[01:13] Daphna Barbeau: Yeah, it really just feels like it puts you over the edge. But nothing will get in the way of doing Journal Club. I think it's good for us. It centers us, and it's good for the community. So here we are.

[01:29] Ben Courchia, MD: While we're venting, we just want to remind people that we're going to let the survey run for a couple more weeks. We're celebrating the five-year anniversary of the podcast and we're going to have our usual feedback survey. Feel free to go and fill it out. We take the survey results very seriously — all the changes you've seen happen on the podcast over the years are driven by survey results. And we have lots of gifts we're hoping to send to people just for thanking them for their time in sharing their thoughts, because we believe that is not taken for granted.

[02:07] Daphna Barbeau: Reading the survey is something that is the opposite of disgruntling — and that doesn't mean people can't be constructive. We've changed a lot of things based on that feedback.

[02:18] Ben Courchia, MD: Yeah, a lot of things. For example, people say things like, "I have trouble finding the episodes." So it's not all flowers.

[02:24] Daphna Barbeau: Please do be constructive. It actually makes us feel quite good when the community is engaged in making the platform better — that's what we've always wanted.

[02:35] Ben Courchia, MD: When the feedback is constructive, it also gives us a hint that people have been listening and engaging with the platform. All right.

[02:41] Daphna Barbeau: We'll take all comers. Please leave your feedback, and thank you to everyone who has been leaving feedback on their podcast streaming app — that's always nice.

[02:53] Ben Courchia, MD: We have a new comment on the Apple Podcasts platform. If you have the time and want to leave us a five-star review or a little feedback, it helps the platform a lot. This one is from Junior Neo Attending — I'm assuming somebody who recently graduated. They said: "I've been listening to The Incubator in various forms for several years now and continue to find it helpful with staying up to date with current topics and controversies, and learning the historical context behind disease processes." This person mentions they particularly loved the episodes on hypoxic-ischemic encephalopathy (HIE) and therapeutic hypothermia reviewing physiology. "Thank you, Daphna and Ben, for providing such an easily accessible forum that covers so many layers of neonatology, inclusive of not just neonatal expert opinion, but also parental values. It is what I listen to on my daily drive to and from the unit." Lovely.

[03:49] Daphna Barbeau: We love that. Thank you for writing.

[03:51] Ben Courchia, MD: Thank you, Junior Neo Attending. Okay. The first paper we're reviewing this week is from JAMA Network Open. Very interesting subject: phototherapy, morbidity, and mortality in very preterm infants. The first author is Imoki Deshman — I'm going to mispronounce that — and this is a paper out of Sweden.

[04:20] Ben Courchia, MD: It's a very interesting topic, obviously, because we're talking about phototherapy in very preterm infants — something we're still not entirely sure about. The background notes that almost all preterm neonates develop hyperbilirubinemia within the first two weeks of life, and that excessive bilirubin concentrations can lead to neurological dysfunction, sometimes even permanent brain injury in the form of kernicterus. The introduction of phototherapy has substantially lowered the incidence of excessive bilirubin levels and kernicterus. Phototherapy has also been proven to reduce the need for exchange transfusion for hyperbilirubinemia — I think that's the classic board question where they ask what the effect of phototherapy is, and we all tend to think it lowers the bilirubin, but the data was actually driven to find out whether it reduced the need for exchange transfusion. And that's obviously a very big deal. The striking statistic in the background is that more than 80% of extremely preterm newborns have been reported to be treated with phototherapy, so most very preterm babies do get some form of phototherapy at one point or another.

[05:52] Ben Courchia, MD: Now, there is emerging evidence suggesting that phototherapy may be harmful and overused in preterm infants. A paper I pulled from the Journal of Perinatology, dating from 2012, from the Neonatal Research Network, is called "Does Aggressive Phototherapy Increase Mortality While Decreasing Profound Impairment Among the Smallest and Sickest Newborns?" — first author John Tyson. It's always very interesting to see what the supposed effect of phototherapy can be on neonates. Phototherapy has been associated with increased dermal water losses, delayed circulatory adaptation, and feeding intolerance. More importantly, a secondary analysis of a randomized clinical trial indicated that aggressive phototherapy among newborns with birth weights between 500 and 750 grams reduced neurodevelopmental impairment at the cost of higher mortality. In an earlier US study, newborns with a birth weight of less than 1,000 grams who received phototherapy had a 19% increased mortality rate.

[06:44] Ben Courchia, MD: The primary aim of the study we're reviewing today is this nationwide population-based cohort study testing the association between the duration of phototherapy and neonatal mortality in very preterm newborns, with major neonatal morbidities as secondary outcomes. To evaluate any confounding, they also tested the association between bilirubin levels and neonatal mortality and morbidity, with and without restriction for conditions known to contribute to phototherapy use and mortality.

[07:20] Ben Courchia, MD: The study was approved by Swedish authorities in 2024 and used the SNQ — the Swedish Neonatal Quality Register — a database we've referenced on the podcast through various studies and a very robust one. Between November 2015 and December 2024, almost 9,000 neonates were born between 22 weeks and 31 weeks and 6 days and admitted to the NICU. Of those, 2,647 were ineligible because they were cared for in units that did not report daily exposure data on phototherapy duration or peak bilirubin. Among the remaining newborns, they excluded babies who died within the first few days after birth and babies with congenital anomalies, leaving them with almost 664 newborns with complete data.

[08:50] Ben Courchia, MD: The primary exposure was the duration of phototherapy in days during the first week of postnatal life. Phototherapy within 24-hour increments was reported as either started, ongoing, or stopped on the day of charting — and any of those registrations on a given day was categorized as a day with phototherapy. Three categories were defined: zero to three days, four to five days, or six to seven days. Other exposures included peak bilirubin, defined as the highest serum value registered for each newborn, and the area under the curve (AUC) in the first week after birth. The analysis included a total of about 22,000 bilirubin values. Bilirubin percentiles were calculated across two gestational age strata and four categories: 25th percentile or below, 26th to 50th, 51st to 75th, and above the 75th percentile.

[09:35] Ben Courchia, MD: Now, how did they manage phototherapy in preterm newborns in Sweden? The Swedish guideline for treatment of neonatal hyperbilirubinemia recommends phototherapy in cycles of two to four hours, followed by a break for feeding and nursing care, after which phototherapy was resumed. They did not have a specific protocol for when to start phototherapy for hyperbilirubinemia.

[10:52] Ben Courchia, MD: The primary outcome was late neonatal mortality on postnatal days 8 to 27. Secondary outcomes included a composite of severe neonatal morbidity: intraventricular hemorrhage (IVH) grade 3 to 4, patent ductus arteriosus (PDA) treated pharmacologically or surgically, necrotizing enterocolitis (NEC) stage 2A or higher, severe bronchopulmonary dysplasia (BPD) defined as greater than or equal to 30% supplemental oxygen at 36 weeks, and retinopathy of prematurity (ROP) treated with laser, anti-vascular endothelial growth factor (anti-VEGF), or surgery.

[11:26] Ben Courchia, MD: Let's get into the results. In this cohort study of 4,917 neonates — 1,800 born extremely preterm at less than 28 weeks, and 3,162 born very preterm at 28 to 31 weeks — the median gestational age was 29 weeks and the median birth weight was 1,180 grams. Importantly, 36% of the cohort weighed less than one kilogram. Overall, 95.5% were treated with phototherapy — even higher than what they reported in their methods. The number of days on phototherapy was higher for babies born at lower gestational ages: the smaller and more immature, the more likely to have extended days on phototherapy.

[12:20] Ben Courchia, MD: Late neonatal mortality — the primary outcome — occurred in 1.7% of the cohort treated for zero to three days, 2.9% for those treated four to five days, and 4.6% for those treated six to seven days. I invite you to look at Figure 1, because you might think there's a clear progression — and it seems like the longer you're on phototherapy, the more likely you are to have late neonatal mortality. But when you look at the confidence intervals, it's not statistically significant. Excluding newborns with IVH grade 3 to 4, isoimmunization, or Apgar scores below 4 at five minutes did not change the results, and neither did extending the mortality endpoint from day 27 to hospital discharge.

[13:15] Ben Courchia, MD: What I wanted to focus on is the finding that was actually significant — unfortunately not the primary outcome, but severe neonatal morbidity (SNM). It occurred in 10.7% of infants treated for zero to three days, 17% in those treated four to five days, and 28.3% in those treated six to seven days — and that was statistically significant. So the longer on phototherapy, the more likely to have a severe neonatal morbidity. These associations were limited to newborns between 26 and 31 weeks — when you look at babies between 22 and 25 weeks, the association doesn't hold. And this finding could be largely attributed to higher prevalence of IVH grade 3 to 4 and severe BPD in newborns receiving phototherapy for six to seven days. Interestingly, phototherapy for six to seven days was associated with decreased odds of treated PDA in newborns born at 22 to 25 weeks — always a subject of controversy. Phototherapy duration was not associated with NEC or ROP in any gestational age stratum.

[15:33] Ben Courchia, MD: Going back to late neonatal mortality — it was not related to peak bilirubin levels and occurred in 2.5% with a peak bilirubin below the 25th percentile and 3% above the 75th percentile, so not much difference across those thresholds. A peak bilirubin above the 75th percentile was associated with increased odds of the composite severe neonatal morbidity compared to below the 25th percentile, and after stratification this association remained significant only in babies at 30 to 31 weeks gestational age.

[16:17] Ben Courchia, MD: The conclusion: in this cohort of very preterm newborns, the duration of phototherapy was not associated with neonatal mortality. However, a longer duration was associated with increased odds of some severe neonatal morbidities. Even if this association may have resulted from some confounding, the findings underscore recommendations to reduce unwarranted phototherapy exposure in very preterm neonates. And I think that's really the point of discussion — we use a lot of phototherapy assuming it's very safe with very little side effects, but this is the kind of data that should give us pause to rethink how long we keep a baby under phototherapy.

[17:03] Daphna Barbeau: Yeah. For me it highlighted two things. One — and I think we forget this — bilirubin is probably also kind of an inflammatory marker. The sickest babies have the most prolonged needs. They tried to account for some of that, but there's some of it we just can't account for without a really, really good severity score. And second, I think even if it were just the water losses or the temperature changes from the lights, we should be cognizant of that — especially in the smallest babies. Rather than just leaving a baby on continuously for a week, which I think some colleagues have done — I'm not sure that's the right practice given the data we do have.

[18:02] Ben Courchia, MD: And we have very arbitrary values for phototherapy thresholds. For some of the smaller babies, some people say if it's above 5, start it. And then if the bilirubin is 5.6, 5.2, 5.1 — they remain on phototherapy even if it's relatively stable. I'm not blaming the practice, I'm just saying we really have no idea what we're doing at that point. So I think this is something we'll have to rethink. It's interesting also to see what is considered safe for a preterm. We had a very interesting episode series on the podcast a while back about rethinking phototherapy — it mostly focused on full-term infants. We spoke with Dr. Alex Kemper, one of the authors of the AAP guidelines, and Dr. Dan Rauch. We also had a very interesting discussion with Dr. Deepak Mehta about how we think about phototherapy in preemies — he wrote a nice NeoReviews paper on the subject, which I'd refer you to.

[19:36] Daphna Barbeau: The other thing that complicates all of this — related to that series — is that we can talk about duration of phototherapy, but we don't always capture the intensity. How much phototherapy are we giving? It may be many days at low intensity, or just a few days at high intensity. I'm not sure we've looked at this in a granular enough way.

[20:09] Ben Courchia, MD: Right — are we measuring the intensity of phototherapy every time we touch the baby, every time we adjust the light? These are important considerations. But I am always fascinated by interventions we consider super safe. 95% of that cohort was exposed to phototherapy — what else do we do to babies at a 95% rate? And for us to do that with so little evidence behind it is kind of remarkable. We're going to have a discussion soon about erythropoiesis-stimulating agents (ESAs) — there's so much data and yet the debate continues about whether to use them — and yet phototherapy, with far less data, is essentially universal. It's always interesting how we agonize over starting something with robust supporting data, but something with very little data becomes standard of care.

[21:15] Daphna Barbeau: Yeah. The standard of care.

[21:18] Ben Courchia, MD: 95% for very preterm babies — and we're not talking about bilirubins of 12. We're starting phototherapy for levels below 10 without knowing what the real target should be. It's fascinating. 

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[00:08] Daphna Barbeau: Well, I'm going to take your primer on neonatal hyperbilirubinemia and talk about this article — which made me go, "what?" It's entitled "Renal Ultrasonography Findings Are Associated with Urinary Tract Infection in Neonates with Asymptomatic Hyperbilirubinemia," published in the Journal of Perinatology. The lead author is Amin Ergul-Sari and the senior author is Ozgul Saluglu. This is coming to us from Istanbul. I'll admit I'm of Turkish descent and have very little Turkish proficiency, so — shame on me.

[01:04] Daphna Barbeau: The objective of this study was to look at clinical, laboratory, and ultrasound factors associated with urinary tract infection (UTI) in neonates hospitalized for unexplained hyperbilirubinemia. The introduction is valuable. As we mentioned, neonatal hyperbilirubinemia is among the most frequent clinical conditions requiring medical attention and even hospital readmissions in the early postnatal period. While the majority of cases are physiologic and typically benign, even indirect hyperbilirubinemia can serve as a sentinel sign of something concerning — especially UTI. The prevalence of UTI in asymptomatic neonates presenting with unexplained jaundice has been reported to range from 6% to as high as 11%. The pathophysiological link is multifactorial, but it's hypothesized that gram-negative bacteria — particularly E. coli — release endotoxins that can lead to cholestasis, resulting in elevated bilirubin levels even in the absence of systemic sepsis.

[02:30] Daphna Barbeau: This was a retrospective observational cohort study conducted at one level three NICU, looking at records of all neonates hospitalized for the management of hyperbilirubinemia between January 2013 and December 2017. They included term and near-term neonates — anyone greater than or equal to 37 weeks gestational age — hospitalized for jaundice requiring phototherapy according to the AAP guidelines at that time, which have since been updated. Patients were included only if they had no identifiable cause for jaundice other than a potential UTI. Asymptomatic hyperbilirubinemia was defined as the absence of fever, feeding intolerance, respiratory distress, lethargy, or hemodynamic instability at admission. Exclusion criteria included hemolytic disease of the newborn, known glucose-6-phosphate dehydrogenase (G6PD) deficiency — which is at even higher rates in that population — major congenital urinary tract anomalies, history of perinatal asphyxia, evidence of systemic sepsis or meningitis, and prior antibiotic use.

[03:20] Daphna Barbeau: A confirmed UTI was defined as: one, a positive urinalysis — presence of leukocyte esterase on urine dipstick and pyuria defined as greater than five white blood cells per high power field on microscopic examination — and two, a positive urine culture with growth of a single uropathogen at a colony count of greater than or equal to 50,000 CFU. Specimens with mixed growth, low colony counts, or lacking associated pyuria were classified as contaminants. All neonates underwent renal and urinary tract ultrasound within the first 48 hours of admission.

[04:00] Daphna Barbeau: A total of 96 neonates were included. Based on culture results, 30 neonates — 31.2% — were diagnosed with culture-proven UTI, while 66 — 68% — had negative cultures. So a third of babies admitted for hyperbilirubinemia had culture-proven UTIs. There was a statistically significant difference in gestational age: neonates in the UTI-positive group were born at a slightly lower gestational age — 37 ± 1.36 weeks versus 37 ± 1.28 weeks. There were no significant differences in birth weight, gender, or mode of delivery. Mean hospital stay was slightly longer in the UTI group, but this was not statistically significant.

[05:35] Daphna Barbeau: Neonates in the UTI group were significantly older at presentation — 8.4 ± 5 days versus 4.8 ± 2 days in the non-UTI group. In a subgroup analysis, late-onset presentation at greater than or equal to seven days of life was significantly associated with a higher risk of UTI — I thought that was one of the most impressive findings. Laboratory values at admission did not distinguish the groups: total bilirubin, direct bilirubin, white blood cell counts, and C-reactive protein (CRP) levels showed no statistically significant differences. The most frequent uropathogens were Klebsiella and E. coli. All neonates in the UTI group had significant pyuria, while neonates in the control group had normal urinalysis findings.

[06:30] Daphna Barbeau: Pathological renal ultrasound findings were significantly more frequent in the UTI group — 30% (9 babies) — compared to controls — 9% (6 babies). Among UTI-positive neonates with pathological urinary tract findings, the most common anomaly was pelvicaliectasis followed by hydronephrosis. In contrast, all pathological findings in the control group were isolated pelvicaliectasis — no cases of hydronephrosis. The authors highlight that this likely indicates that mild dilation is common, but hydronephrosis in this cohort was exclusively clustered within the UTI-positive group. In a multivariate model including gestational age, gender, and ultrasound findings, pathological renal ultrasound findings were independently associated with UTI — neonates with structural anomalies were 4.6 times more likely to have a concomitant UTI.

[07:48] Daphna Barbeau: Their conclusions are that the study demonstrated a high prevalence of UTI — 31% — among neonates hospitalized for unexplained hyperbilirubinemia, and identifies renal ultrasonographic abnormalities as the factor most strongly associated with UTI. And again, this was a group of babies sick enough to need hospitalization for phototherapy — so a sicker group than the general population. But I think it should give us pause. Sometimes we use the white blood cell count to try to rule out infection. In our practice, we are sending blood cultures for babies admitted with high bilirubin levels.

[09:09] Ben Courchia, MD: Hold on — I'm going to push back. I don't think we order blood cultures on everybody admitted for hyperbilirubinemia.

[09:22] Daphna Barbeau: I do, especially if they need to come back to the NICU with our new bilirubin thresholds. I don't put them on antibiotics, but I send the culture.

[09:30] Ben Courchia, MD: We're going to get a lot of emails about that.

[09:42] Daphna Barbeau: Listen, if somebody can show me the global policy on obtaining blood cultures, I'm happy to follow it.

[09:50] Ben Courchia, MD: My point here is that that's the real discussion — a baby comes back for hyperbilirubinemia, do you get a blood culture or not? Maybe you should just get a urine culture.

[10:04] Daphna Barbeau: Yeah, that's really what this says to me — UTIs are much more likely to be the problem than sepsis in a well-appearing baby. How many blood cultures have we had come back positive in recent memory? None.

[10:20] Ben Courchia, MD: No — you'd get a positive blood culture on a kid with urosepsis, but that kid would be really sick. So it might be much higher yield to just get a urine culture. This is what makes the data interesting. I tend to dismiss retrospective studies unless the effect size is impressive — and this one is small, fewer than 100 patients. But that finding from Figure 1, 30% pathological renal ultrasound findings in the UTI group versus 9% in controls — that's not close. And it reflects a lot of our clinical reality. I also love that they included CRPs, since we send a lot of them in our unit. And they were essentially normal — 0.28 versus 0.31. No help whatsoever. Same with the white blood cell counts — 14 versus 13, nothing to write home about, especially if obtained by heel stick. And the direct bilirubin wasn't meaningfully different either.

[11:37] Daphna Barbeau: Yeah. We tend to think of direct hyperbilirubinemia as the trigger to look for UTI, but indirect? We're less worried. So which baby are we not worried about? The baby that lost weight — we say, "oh, probably not eating enough." But maybe they're not eating enough because they don't feel well. Which baby can we look at and say this is definitely physiologic? It gives me pause.

[12:07] Ben Courchia, MD: That reminds me — my first real ear-pulling as an attending was related to this. I admitted two babies in a row with hyperbilirubinemia and got blood cultures on both — a practice I'd picked up in fellowship. The medical director at the time sent an email to the entire group, in a very non-accusatory way, saying that the practice for babies admitted with hyperbilirubinemia was not to get blood cultures. You know the kind — the email goes to everyone, but you know it's for you. I went to him afterwards and said, "I think that was for me." He said, "Yep, that was for you."

[13:16] Daphna Barbeau: I remember those emails. And for anyone listening — Dr. Doron, wonderful medical director. He never made things punitive. But you still knew. You always knew it was you.

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[01:01] Ben Courchia, MD: In the Journal of Pediatrics, there's a paper by Rachna Mamidi, last author Cindy McEvoy, titled "Extended Continuous Positive Airway Pressure in Infants Born Preterm Decreases Intermittent Hypoxemia: A Secondary Analysis of a Randomized Controlled Trial." We recorded with Dr. McEvoy a while back to discuss her work on extended CPAP — that's episode 346, and it's one of the most visited pages on our website. And while we're on the topic of extended CPAP, I want to bring attention again to a documentary published by my good friend Dr. Guilherme Santana from Montreal Children's, who is now also a colleague of mine since I've been doing hemodynamics over there. It's about the history of bubble CPAP and the Columbia approach. It's a great documentary, very professionally produced, watches like a movie. It walks you through the history of CPAP, how we arrived at bubble CPAP, and references Dr. McEvoy's work on extending CPAP for better lung function at discharge. You can find it on YouTube by searching "Bubble CPAP and the Columbia Approach." One more thing: you always hear about the Columbia approach, but you hear less about Dr. Wong, who is a very private person. He's prominently featured in this documentary and gets to explain how he came up with bubble CPAP. Worth watching.

[03:39] Daphna Barbeau: Yeah, it's so important to know where we came from. Thank you for sharing it.

[03:46] Ben Courchia, MD: All right. So the background of this paper is interesting. Among preterm infants in the NICU, episodes of intermittent hypoxemia are common, multifactorial, difficult to prevent, and importantly, associated with adverse outcomes down the road. What remains fascinating is that there is still no consensus regarding the saturation threshold and duration that constitutes a clinically significant intermittent hypoxia event. If your unit targets 88% saturations, that might be considered a desaturation in our unit. That variability still exists today on such a fundamental question. In a prior randomized controlled trial, Dr. McEvoy's group demonstrated that among preterm infants who met respiratory stability criteria including breathing room air, extending CPAP therapy by an additional two weeks compared to discontinuation resulted in higher functional residual capacity (FRC) when evaluated in the NICU after extended CPAP was stopped. That intervention also resulted in improved lung growth assessed during infancy following NICU discharge. The hypothesis for this particular secondary analysis was that infants randomized to extended CPAP, compared to those who had CPAP discontinued, would have fewer episodes of intermittent hypoxemia and significantly higher saturations during the two-week treatment period.

[05:30] Ben Courchia, MD: This is a single-center, prospective, pre-specified secondary analysis using physiologic pulse oximetry data collected as part of the NHLBI-funded Extending CPAP Therapy in Stable Preterm Infants to Increase Lung Growth and Function randomized clinical trial. The trial included infants born between 24 and 32 weeks gestation who required CPAP for more than 24 hours and met specific respiratory stability criteria: for more than 12 hours at less than 35 weeks, they were on Hudson prongs with a chin strap. CPAP was exclusively administered using bubble CPAP. There was no standardized supplemental oxygen protocol; oxygen could be administered at the discretion of the clinical team. Infants were stratified by gestational age and randomized to 14 days of extended CPAP or discontinued CPAP on unassisted room air. Of the 100 randomized infants, 95 met the pre-specified inclusion criterion of having pulse oximetry data available for more than 75% of the extended period, consistent with prior published studies, and were included in the analysis: 50 in the extended CPAP group and 45 in the discontinued CPAP group. During the 14-day randomization period, a second pulse oximeter with a two-second sampling rate was placed on each infant with alarms silenced and the display concealed. This was an important methodological decision: as a single-center study, the unit had specific saturation targets, and this additional pulse oximeter allowed faster data averaging and enabled the team to evaluate different thresholds. Bedside caregivers responded to intermittent hypoxia and apnea episodes according to standard NICU practices, including airway repositioning and escalating tactile stimulation for apneas greater than 20 seconds, or shorter apneas associated with bradycardia or desaturation. Desaturation in their unit was defined as less than 88%. In the discontinued CPAP group, intermittent hypoxia episodes alone did not trigger a return to CPAP; supplemental oxygen was permitted per clinical guidelines if saturations remained low. Infants with clinically significant intermittent hypoxia who also met additional failure criteria — increased work of breathing, tachypnea, or increased apnea — were placed back on CPAP. FRC was measured prior to randomization and at the end of the two-week treatment period using a nitrogen washout technique. The predefined primary outcome was the number of intermittent hypoxia episodes with saturations below 90% lasting 10 to 300 seconds during the 14-day treatment period. This is where the second pulse oximeter was particularly useful: for the purposes of this study, hypoxia was defined as below 90%, a threshold below which the clinical team would not have intervened anyway given their unit's targets. A clever methodological workaround.

[09:44] Ben Courchia, MD: Results. Clinical characteristics between the groups were comparable and demographics were similar between the overall randomized cohort and the 95 included patients. For the primary outcome, infants in the extended CPAP group had significantly fewer episodes of intermittent hypoxemia with saturations below 90% compared to the discontinued group. Want to guess the numbers?

[09:51] Daphna Barbeau: I have it pulled up right here, go ahead and tell the people.

[09:56] Ben Courchia, MD: 57.6 events in the extended CPAP group compared to 151.7 in the discontinued group, with an adjusted difference of negative 94.1. Statistically significant, with confidence intervals from minus 132 to minus 56.

[10:14] Daphna Barbeau: That's almost double.

[10:21] Ben Courchia, MD: Secondary outcomes showed that the extended CPAP group experienced significantly fewer standardized episodes of intermittent hypoxemia across all thresholds and durations assessed. Despite both groups requiring no supplemental oxygen, the extended CPAP group had significantly higher mean saturations on room air: 95.9% versus 94.7%, statistically significant. I also want to mention that in our unit we extend CPAP until 32 weeks, but the enrollment data shows that these were quite mature babies, extended all the way to 34 or 35 weeks. Infants randomized to extended CPAP also had significantly increased FRC at the end of the two-week treatment period compared to the discontinued group. There was a statistically significant negative correlation between intermittent hypoxemia counts and increasing FRC per kg on day 14: the more intermittent hypoxemia events, the lower the FRC. There was also a significant treatment effect, with the extended CPAP group shifted toward higher FRC and lower intermittent hypoxemia. The authors also explored the mechanism: since extended CPAP demonstrated increased FRC, decreased intermittent hypoxemia, and increased baseline saturations, they wanted to evaluate whether the treatment effect on intermittent hypoxemia was mediated through the saturation effect. They found that a large portion of the effect on decreasing intermittent hypoxemia was indeed mediated through the increase in saturations. That said, there remained a significant direct effect of extended CPAP on decreasing intermittent hypoxemia independent of that saturation increase. In conclusion, the authors state that among stable preterm infants treated with nasal CPAP in the NICU, extending CPAP for two weeks on room air significantly reduced the number and duration of intermittent hypoxemia episodes compared to unsupported room air. These findings highlight a potentially important benefit of extended CPAP for stable, convalescent preterm infants to reduce intermittent hypoxemia and potentially improve outcomes. A simple, non-pharmacologic approach — though further studies are necessary. Strategies aimed at limiting intermittent hypoxemia could potentially alleviate common morbidities associated with prematurity. Very interesting study. The gift that keeps on giving. Daphna, any thoughts?

[13:52] Daphna Barbeau: I think the key take-home for me was that we thought we were already doing extended CPAP by keeping kids to 32 weeks. But this is kids kept an additional two weeks beyond when someone would have taken them off based on their respiratory scores. For some kids that's 33 weeks, some 34 weeks, some potentially longer.

[14:21] Ben Courchia, MD: And that's where I have some concern, because unit practices play a huge role here. There is data to support feeding babies on CPAP, and if you're a unit that's comfortable doing that, this data is very relevant. But if you're a unit like ours, where the reluctance is to feed babies by mouth while on CPAP, then extending to 34 weeks raises real questions.

[14:46] Daphna Barbeau: Don't get me started. You know how I feel about that.

[14:51] Ben Courchia, MD: I know. But the concern is real: if I were implementing this somewhere, it would have to go hand in hand with a feeding protocol so you don't miss that developmental window for oral skills. That's not a critique of the paper — that's not the point of the study. But it's one of the unintended consequences to consider when implementing certain interventions.

[15:56] Daphna Barbeau: And we discussed this with Dr. McEvoy. Was there a longer time to full oral feeds? Her answer was no. And part of that is because many units don't even start oral feeds until after 34 weeks anyway. So there's still room to play. And it doesn't have to be all or nothing. Maybe we go to 33 weeks instead of 32.

[16:20] Ben Courchia, MD: For sure. And I also want to say that the data does support feeding on CPAP. It's just a significant cultural shift. Easier said than done.

[16:37] Daphna Barbeau: Well, thank you for highlighting that.

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[00:05] Daphna Barbeau: I have another UTI paper for you.

[00:09] Ben Courchia, MD: You're on a UTI tear this week.

[00:12] Daphna Barbeau: I don't know. I feel like we've been seeing more UTIs over time. Maybe I'm the only one that feels that way.

[00:19] Ben Courchia, MD: I think people don't know that in the unit, when Daphna sends a urine culture and it comes back positive, aside from the fact that we're not happy for the patient, you almost feel vindicated. A little sense of happiness: I got it. Yes.

[00:28] Daphna Barbeau: No, very disappointed.

[00:34] Daphna Barbeau: I found it. I figured it out. And people should know: I'm not just going around sending urine cultures on everybody. It's the spidey sense, the marginally symptomatic baby.

[00:50] Ben Courchia, MD: UTIs are usually not the most symptomatic type of events. They require a little bit of sensitivity when it comes to investigating. So when you pull the trigger and you're correct, there's something a bit addictive about that.

[00:57] Daphna Barbeau: That's right, they're insidious.

[01:15] Daphna Barbeau: I'm right more often than I'm wrong. So there's that.

[01:23] Ben Courchia, MD: Alright, enough of the inside look at our practice.

[01:28] Daphna Barbeau: All right. So this paper is entitled "Urinary Tract Infection in the Neonatal Intensive Care Unit." It's in the Journal of Perinatology, coming from Nationwide Children's Hospital, as part of their neonatal antimicrobial stewardship program called NEOASP. Lead author Jacqueline Magers, senior author Pablo Sanchez.

[01:52] Ben Courchia, MD: Pablo Sanchez has published a lot on this subject and on their antimicrobial stewardship program, which is quite phenomenal.

[02:03] Daphna Barbeau: Yes. And given all the UTIs, it would be nice if we could treat them for a shorter time.

[02:11] Ben Courchia, MD: I have a story about Pablo Sanchez to share at the end.

[02:14] Daphna Barbeau: Now you have to stick around and listen. Okay. So the objective was to determine adherence and safety of a diagnostic and therapeutic guideline for culture and urinalysis-proven urinary tract infection in the NICU. They were really looking at whether a shorter treatment course was feasible. The NEOASP recommendation is a five-day antibiotic course for non-bacteremic UTI. Some background: UTI is the most frequent serious bacterial infection in early infancy, occurring in 5 to nearly 15% of infants — so it is not unreasonable to go looking for them in a symptomatic baby. The prevalence among preterm and high-risk neonates in the NICU has been estimated even higher, up to 25% of premature infants. In 2019, the NEOASP and its seven affiliated NICUs implemented a guideline requiring urinalysis for pyuria in addition to bacterial culture, and instituted a formal timeout for UTI treatment in infants without concomitant bacteremia or meningitis. That timeout was a structured pause for the whole team to ask: does this baby meet our criteria for the five-day course? It required strong multidisciplinary support, especially from pharmacists, to ensure adherence.

[04:55] Daphna Barbeau: The study included all infants who received antibiotic therapy for a UTI diagnosis at Nationwide Children's Hospital between November 2020 and December 2022. Infants were excluded if they had concurrent bacteremia or meningitis, fungal growth on urine culture, or urine obtained via nephrostomy catheter. Infants were identified by the NICU pharmacist during daily Monday-to-Friday patient rounds and twice-weekly antimicrobial stewardship meetings, where all infants on antibiotics were discussed and real-time recommendations were provided to the attending neonatologist. Evaluation for possible UTI was preferred among infants greater than three days of age when late-onset sepsis was suspected. All components of the sepsis evaluation remained at the attending's discretion. Empiric antibiotic therapy for suspected late-onset sepsis was nafcillin and gentamicin in infants without MRSA colonization; those with known MRSA colonization received empiric vancomycin plus gentamicin. When UTI was strongly suspected, ampicillin was offered as an alternative to nafcillin. Subsequent antibiotic therapy was driven by urine culture results. Definitive antibiotic therapy was defined as the treatment course determined by the team based on clinical course, urine culture, urinalysis, and susceptibility testing. Safety outcomes were defined a priori as reinitiation of antibiotic therapy within seven days after completing the definitive course for the same organism, as well as overall sepsis-related mortality while in the NICU.

[07:05] Daphna Barbeau: Results. During the 26-month study period, 77 infants were diagnosed with 93 bacterial UTIs. Two additional infants had Candida on urine culture and were excluded. The first UTI episode occurred at a median of 43 days of life. Median gestational age at birth was 30 weeks, birth weight approximately 1,300 grams, and 66% of infants were male. Of the 77 infants, 81% met the diagnostic criteria recommended by the guideline. Of those who did not, 12% (nine out of 77) had fewer than 50,000 CFU on culture but had pyuria with 8 to 136 white blood cells per high-power field and were included. One additional infant received treatment without a urine culture being obtainable. The majority of infants (58%) had normal renal ultrasounds. A VCUG was performed in 17% of infants; eight of those 13 (62%) were normal. Vesicoureteral reflux was identified in the remaining five.

[08:30] Daphna Barbeau: Sixteen percent of infants received treatment for more than one UTI episode. Nine infants had one subsequent episode, two had two subsequent episodes, and one had three, for a total of 16 additional UTI episodes among 12 infants. None of the subsequent UTIs were associated with bacteremia. Of those 16 episodes, 63% met the diagnostic criteria per guideline. The median time between UTI occurrences (from the last day of antibiotic therapy for the first UTI to the first day of the subsequent UTI) was approximately 21 days, with a range of 8 to 44 days. The same organism from the previous UTI was isolated in 9 (56%) of the 16 subsequent episodes. Of the 12 infants with subsequent UTIs, 33% had antibiotics reinitiated within seven days after completing the initial definitive course, but only one of those episodes was due to the same organism. So to be clear: there were some repeat infections with the same bacteria, but most occurred in babies who had already gone at least a week between antibiotic courses. Among those who restarted antibiotics within a week, only one case was due to the same organism. The team concluded a failure rate of 1%. None of the infants were receiving antibiotic prophylaxis at the time of the second UTI. Two infants received amoxicillin prophylaxis after a second episode. Five of the 12 infants with recurrent UTIs had normal VCUGs; two (17%) had vesicoureteral reflux; five (42%) did not have a VCUG performed.

[11:00] Daphna Barbeau: Eighty-eight percent of all urine cultures were obtained by catheterization. Overall adherence to guideline criteria was 77%. The most frequent organisms across all groups were Enterococcus faecalis and E. coli, followed by other gram-negative bacilli. Regarding antibiotic therapy: 49% of UTI episodes were treated intravenously, with 37% transitioned to an enteral agent, most commonly on day three. Exclusively enteral antibiotic therapy was used in 14% (13 of 93) of episodes. The median duration of antimicrobial therapy was five to six days regardless of whether the route was intravenous or enteral. Of the 91 infants who completed treatment while in the NICU, 71% received five calendar days and 16% received six calendar days; only 2% received four days. The majority of UTIs were treated with gentamicin (31%) or ampicillin (15%). Four infants died following UTI diagnosis; one died within seven days of stopping antibiotic therapy, an infant with AV canal defect and complications of prematurity including BPD and pulmonary hypertension. None of the deaths were felt to be associated with UTI recurrence. The authors conclude that the five-day treatment course was associated with a 1% failure rate defined as reinitiation of antibiotics within seven days for the same organism.

[12:50] Daphna Barbeau: I thought this was a really interesting paper. I love the idea of a five-day course. I'm also really drawn to the concept of enteral therapy, and I wish we had a bit more data on that. I think the question we all have to sit with is: is seven days enough to call something a recurrence versus a treatment failure?

[13:09] Ben Courchia, MD: Let's go back to the key numbers because it's worth restating clearly. Antibiotics restarted within seven days of completing UTI treatment: 12 infants, 15%. Antibiotics restarted for a subsequent UTI within seven days: 4%. Same pathogen as the previous episode: 1%. That's one case. One. And I'm going to say something that will frustrate the infectious disease community: is the difference between five and seven days really that significant?

[14:04] Daphna Barbeau: Maybe.

[14:08] Ben Courchia, MD: I'll be honest. If a baby is waiting for UTI treatment completion before going home, 48 hours makes a dramatic clinical difference. That's 48 hours that baby could be at home. So in that context, yes, it's clinically meaningful. But the question is: does the data support changing to five days?

[14:54] Daphna Barbeau: A few things before I answer. The nurses listening would say the difference between five and seven days with a peripheral IV absolutely matters. And if you're talking about moving to enteral therapy, that's a separate conversation worth having. There are a lot of units that never offer enteral treatment for UTIs. This paper makes me reconsider that.

[15:19] Ben Courchia, MD: Which is interesting, because the broader field of pediatrics has already moved toward enteral antibiotics for UTI. The absorption question in very preterm infants is real, but it's worth exploring.

[15:36] Daphna Barbeau: Absolutely. And depending on postmenstrual age, whether you want to add another enteral agent — it depends on the case. But if you're telling a nurse to keep an IV in for five versus seven days, or worse, placing a PICC line just for this, that's a big deal.

[16:01] Ben Courchia, MD: Five days of IV antibiotics is, I can say confidently, considered overkill in the broader world of pediatrics. And by the time you have speciation and sensitivities, you've already been on broad-spectrum therapy for at least two days. So the targeted therapy window within that five-day course is actually quite short.

[16:41] Daphna Barbeau: In the adult literature, they're already talking about three days. My main concern with the data here is that the same organism was cultured in 16 subsequent episodes. That's real.

[16:46] Ben Courchia, MD: But these babies aren't going home. A 31-weeker with a UTI isn't leaving the NICU for another month at least. You have the opportunity to reculture them if anything changes. That does affect how you weigh the risk of a shorter course.

[17:14] Daphna Barbeau: I also wonder about the utility of a test of cure.

[17:19] Ben Courchia, MD: Twenty-two percent of infants in this cohort had a test of cure. And yes, the study is small, but anything coming out of Nationwide with Pablo Sanchez's name on it carries real weight. We're not going to reach a formal consensus today, but it's an important conversation.

[17:46] Daphna Barbeau: We don't make formal recommendations here, but this definitely gave me something to think about: shorter courses, and feeling more comfortable about transitioning to enteral therapy when the clinical situation allows.

[18:05] Ben Courchia, MD: Here's how you distort the evidence: on day five, you lose the IV and do the last two days orally.

[18:17] Daphna Barbeau: That's still seven days, Ben.

[18:19] Ben Courchia, MD: That's my point. It's still seven days, but if five days is sufficient according to this paper, and even if absorption of the last two oral doses isn't perfect, it kind of counts.

[18:29] Daphna Barbeau: I think they would argue you do three IV and then switch to a narrow enteral agent.

[18:34] Ben Courchia, MD: At this point I've put the entire infectious disease community on my back and I look forward to your emails.

[18:43] Daphna Barbeau: Please send them. And Dr. Sanchez, we would love to have you on. That's long overdue.

[18:48] Ben Courchia, MD: We should. So here's my Pablo Sanchez story. As a fellow, I had a co-fellow — I won't name them — who was managing a complex infectious disease case in an unusual way. In the morning I asked why, and they said: "I just called Pablo." It wasn't well received by our fellowship program that a first-year would call an outside attending for recommendations at night. But the management was correct. And the fact that Pablo Sanchez took that call in the middle of the night and responded thoughtfully says everything about who he is. Long overdue to have him on the show.

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Eli (00:02.252) The article that we're going to cover here in our session, the article of the week on the podcast, is about something that everybody is talking about. Everybody's talking about it. They won't stop talking about it. I have not really been part of this cultural movement. I must say my cultural consumption is woefully inadequate at this point, but everybody else is talking about The Pitt. That's all everybody's talking about, is The Pitt. If you haven't heard about it, you also should leave your apartment, or your car, or wherever you're listening to this.

Ben Courchia MD (00:55.393) Yeah.

Eli (00:58.54) Because The Pitt is now in a second season on HBO Max. It is a generational depiction of medical care in the US today. It is a show about one inner-city public hospital emergency room that tells so many stories about what it's like to get sick and seek care in this country today, and there have been lots of hot takes on this thing because everybody loves it. Everyone seems to love this show. This is the medical drama that doctors are flocking towards, that laypeople are watching. I think the general consensus is not only are the characters compelling, the scriptwriting gripping, and the scenes harrowing, and not only are the episodes tight and well put together, but it's accurate. It resonates with people because it feels real. There was a really interesting critique of the show by a physician, Dhruv Khullar, who writes for The New Yorker. I will just read Dr. Khullar's summary of his take on The Pitt, and then we'll talk about it. What Dr. Khullar writes in The New Yorker is, "What's special about The Pitt isn't that it's medically accurate. Although it is. I even learned a few things about how to insert an emergency chest tube." He says, "What's special about the show is that it offers a kaleidoscopic view of how societal problems have come to pervade medicine. In recent years, I've written about ER overcrowding, the toll that caregiving takes on family, the physical consequences of global warming, language barriers and healthcare discrimination against parents with sickle cell diseases, corporatization in medicine, and the promise and perils of artificial intelligence. The Pitt handles each of these themes and many more with nuance and grace. It's as if the show's creators absorbed every important conversation in healthcare today and somehow transfigured it into good television." Ben, have you watched The Pitt?

Eli (03:19.862) Have you heard people talking about The Pitt? Where are you on The Pitt?

Ben Courchia MD (03:22.766) Like you said, everybody's talking about it. I went in steps. The first thing that I watched was there was a reference, obviously, in the world of neonatology, that there was a scene in the series, The Pitt. I forget if I believe it's season one, where a mother delivers in the ER and a baby is born needing resuscitation. Everybody was marveling at the fact that the consultants on the show did a phenomenal job because the steps they were using to resuscitate the baby were spot on. So, as an NRP instructor, I was like, let me check it out. Let me see what they're doing. And it's true. It was a very well done scene with a very realistic baby. Sometimes in TV shows, they bring out a newborn and it's clearly a four-month-old. And you're like, okay, they did not have that baby just now. But this was a very, very cool scene. And so then...

Eli (04:11.47) Hahaha.

Ben Courchia MD (04:17.678) I started watching a little bit of season one and I think that what is making this show popular is exactly the reason why I stopped watching it, because it is very realistic. As mentioned in the article, it does not omit or abstract any of the systemic issues that we deal with in medicine. That was the reason why I was like, I'm dealing with this every day and I'm looking for a break once I get home. So for me, that was my cue to move on to something a little bit lighter. But it is true that all these documentaries that took place about taking you behind the walls of the hospital and letting you see what nobody else lets you see... Well, all these documentaries have not done as good of a job as this particular TV show has. And I think that it is quite real. I feel like even the first scene when Noah Wyle, I think is his name, right? The actor, my God, my wife's going to kill me if I don't know this. Noah Wyle. When he walks into the hospital, it resonates with how we all walk in every day to work. The interaction with the different physicians and providers, and the sign-out, and all that stuff.

Eli (05:24.128) Noah Wyle. Yep.

Ben Courchia MD (05:42.262) It is very, very real. I'm not surprised that people are enjoying this because it does probably resonate with some of their experiences in the hospital. But for physicians, it acts as a bit of a mirror. And it does shine a light on some of the things that, to me, are at the root of our collective moral distress. So did you watch The Pitt? You said initially that you were lagging behind, but... Are you just consulting in the capacity of reading The New Yorker or have you given it a try?

Eli (06:16.148) Excellent follow-up question. I have watched a few episodes of the first season. I had the amazing opportunity to interview one of the key brains behind The Pitt, Dr. Joe Sachs, who's an emergency medicine doctor in Los Angeles and the chief screenwriter for The Pitt. I'm hoping we can get him on the podcast. I'm working on it, but...

Ben Courchia MD (06:28.429) Okay.

Ben Courchia MD (06:36.578) Wow.

Eli (06:41.324) Dr. Sachs also was one of the key writers behind ER, which of course was the generational antecedent to The Pitt. Although if you ask the Michael Crichton estate, they have strong feelings about whether The Pitt is that different from ER. In preparation for that interview, I watched a few episodes and I think my sense was very much what you described, which is that this thing just gets it right. All right. Like this.

Ben Courchia MD (07:10.414) A little bit too much.

Eli (07:11.602) Yeah, a little too much. Yeah. Exactly. What I've heard people say is like, if I want to be at work, I'll just go to work. But I think it's interesting that doctors have that sense because at the same time it is that exact sausage-making that is so incredibly opaque to patients on the other side, right? So many patients will sit in their room all day. They wait for us to round in the morning. They'll wait for us to round at night.

Ben Courchia MD (07:19.938) That's exactly right.

Eli (07:39.722) And it's not clear why their kid did or didn't get an MRI that day. It's not clear why we decided to start albuterol nebs that day. These decisions are not clear. And I think this is a window, not only into how the sausage is made—in the same way that Anthony Bourdain's writing about restaurants was telling about how the sausage is made literally in the restaurant industry—but also because it provides humanity to doctors and clinicians and everybody involved. Right. That's one thing that resonated with me, is like every one of these people is imperfect in their own unique little way. As we all are. I think that piece of The Pitt, the compassion to demonstrate the humanity, the imperfections of all of these people working in clinical medicine... I hope is a way that doctors and patients can get closer in real life. When I've had conversations with patients, which I've had lots of conversations with patients about The Pitt, because by the way, it's not just a couple of people who watch this. I think the number of people who watch season two, based on when I last looked, is 50% higher than the number of people who watched season one. I think this data is somewhere on the order of 12 or 13 million.

Ben Courchia MD (09:02.913) It did. It won some awards. I think that probably also brought whoever was still living under a rock to the show.

Eli (09:13.014) Yeah, exactly. But like 12 or 13 million people, that's like 5% of Americans, right? 5% of Americans are watching this TV show. And you can sure as heck bet that if you were to propensity score those people, it is probably the people who are sitting in the NICU all day who are like, "I want to understand this crazy world that I'm sitting in." And so I think in my conversations with the patients, the themes that have come up over and over about The Pitt are not only just kind of...

Ben Courchia MD (09:17.549) Yeah.

Eli (09:41.878) ...laughing about how ridiculous clinical medicine is. But also I think it invites a shared humanity in a way that I'm not sure when we whisk in and out on rounds on a given day that we always invite patients into.

Ben Courchia MD (10:02.83) Yeah, so it's exactly right. It does capture things that, to me, surprisingly, it's taking place in an adult emergency room far away from where we work in the neonatal ICU. For example, the article mentions a scene in one of the episodes, which, to be honest, I have not seen. But basically, a physician is caring for somebody with diabetes, and they have no health insurance, and they cannot afford the insulin anyway. And the patient leaves the hospital against medical advice. I don't think even notifying the team that he or she is leaving. And the physician who was trying to get some supplies ready for the person to go home said, "I had everything ready for some home care stuff." And they discussed Ubering it to his house, and then the physician offered to pay for it. It's like this happens to us every day. Like it happened to me on Friday, right? Like three days ago. We needed some medications. The patient doesn't have a car, can't get there. It's like, "Okay, I'll Uber." And I ended up Ubering this for the patient. But this happens every day. It's the reality. And to me, with a name like The Pitt, I believe that the name of the series is really in reference to the location of the show in Pittsburgh. But it does feel like... it highlights a little bit the pit in which we are in, where we basically have a very broken system. In the show, you find how we collectively have been bending over backwards to try to make up for some of these inefficiencies. It's unclear where we're going to go from there. Because what's very depressing about this show, and probably ultimately the reason why I'm not watching it, is because... the humanity of the characters is what offers the ray of hope for health care in this country. Right. And that's us. And I have no doubt that you display the utmost level of compassion, care and humanity in the unit. I want to believe that I do as well. But it is exhausting and depressing to see that maybe is this it? Is this really what is going to save the system?

Ben Courchia MD (12:28.224) Is us going the extra mile and Ubering things to patients' houses the solution? I really hope not. I would be very happy if this show brings out the right kind of folks to advocate for our health care system and maybe finds a more permanent and sustainable solution. But Yeah, it's done quite well. I'm really excited that you were able to speak to one of the main writers of the show. I don't know if this is a chord that this show struck with you as well.

Eli (13:07.022) Yeah, I'm not sure that you needed to watch The Pitt to know how broken the healthcare system was, or to remind you of it. I think you just need to show up at sign out and pretty soon you realize, you know, the kid who didn't get the ultrasound for whatever reason.

Ben Courchia MD (13:22.722) But do you feel like you show up to sign out and it's like, okay, it's our hospital. It's our broken unit that doesn't work that well. But if I went down the street, this thing would be working well. I feel like by making it a national TV show that is so successful that everybody resonates with, it sort of rings the bell that this is how it is everywhere. It's just the reality. And I think that this is what's really depressing because to me, I feel like my unit is broken in many ways. There's lots of things we're trying to fix, but I have the hope that the folks down the road have it better than me. And it's most likely not true. Despite the prestige of any institution or anything else, or the quality of the physicians. I know this by now. I've been working in this business long enough to know that even some of the best people in our field struggle with some of the stuff that we would never imagine would be a problem for these type of caliber individuals.

Eli (14:01.464) Yeah.

Ben Courchia MD (14:22.39) And yet the system forces us into that position.

Eli (14:25.838) That resonates with me. We had a couple of things happen on night shift a couple of nights ago that I was like, wow, this is where the world comes for answers is this hospital, God forbid. Listen, I think I agree with you that there is something deeply paralyzing and perhaps disappointing that the...

Ben Courchia MD (14:29.069) Haha.

Ben Courchia MD (14:34.956) Yeah.

Eli (14:51.608) problems that we thought were just problems in the family are systematic problems that are thorny and hard to solve. On the other hand, maybe that is the invitation to say, wow. This isn't just our problem. The fact that we can't get people very basic healthcare services isn't just our problem. Obviously, where there are problems, there's frustration and potentially there's also solutions. Actually, the... If we were limited to problems that lived in our little silos that we would try to solve by hook and by crook through quality improvement committees, I think it would be harder to solve problems than the world we're in where there are some deeply patterned, deeply thorny structural problems that it feels like at least we can go after arm in arm. And maybe that's a deeply naive thing to say, but in a world where I think states have been pretty ambitious in terms of trying to step up to the plate and address certain things in the healthcare system, in a world where hopefully there are some insurers out there who are rethinking the way that we provide care. And there are some that are trying to think about, "Can we pay for quality, not for service?" "And does that mean we can do certain things that traditionally we haven't done?" And in a world where doctors are no longer staying in their medical lane and they're saying, "Wow, I have a responsibility. I have a voice. I bear witness to all of this." Maybe that's a world in which, because these problems are not limited just to our family, we can try to think about the next time we're all gathered at Delphi or at PAS or at AAP, we can commiserate about these problems. And then we can say, "Hey, let's go to Sacramento. Let's go to Albany. Let's go to, what's the capital of Florida, Tallahassee. Let's go to Tallahassee." I knew that. Let's go to Tallahassee and let's knock some doors down. I don't know. Who knows.

Ben Courchia MD (16:53.528) Tallahassee.

Ben Courchia MD (17:04.46) We will see. We will see for sure. All right. This was great. I will see you next week for another episode.

Eli (17:11.842) Thanks, Ben.