 On behalf of the McLean Center for Clinical Medical Ethics and the Department of Pediatrics, I'm delighted to welcome you to today's Festrift Honoring Bill Meadow, Professor of Pediatrics and the Director of the Neonatology Fellowship Program. Bill is one of the great clinician scholar educators in the field of neonatology. In recent years, his research has focused on ethical issues in neonatology and has examined questions about resource allocation and informed consent in the NICU. Bill has been the key contributor to our knowledge of prognostication in the NICU setting. I wonder if you'd all join me now to recognize Bill Meadow and his achievements. Bill and I go back a long way to the early 1980s when he was just finishing his fellowship training here at the university, but we really came to know each other when Bill trained in ethics at the McLean Center in 1993-94. We really came to know each other then. The Center hasn't quite been the same since. Bill's involvement made a dramatic difference in the Center's teaching programs and especially in its case conference model. For 10 years before Bill arrived in 1993, the Center's weekly case conference had been a good conference, not unlike many conferences held each week at our medical center and at other medical centers around the country. Bill came along in 93 and suddenly transformed the conference with a vigorous, no-holds-barred debating style in which every voice was heard and in which adversarial verbal exchanges, almost all of them, civil and respectful, became the norm. The air was filled with these intense exchanges, caustic words, seal-tipped irony, and always humor to lighten the burden of making tough decisions where there was no absolutely right or wrong answer. When fellow applicants from around the country visited us at the ethics conference, they would often say to me, gee, Dr. Siegler, I've never seen anything like that. That was wonderful. Bill had changed the conference from a staid, conventional academic meeting to something that was rich, vibrant, thrilling weekly event that no one wanted to miss. Bill and Sue McCrae were in the same fellowship group in 1993-94. That year, Sue, who couldn't join us today, took very careful notes of Bill's comments at the weekly conference. At the end of the year, Sue designed a T-shirt that included some of Bill's views on ethics on the back of the T-shirt. Recently I found one, maybe the only one, of the remaining T-shirts. I show you the back of the T-shirt. These were things that Sue had written down that Bill had said during the year, different ways in which ethics might work in the setting. You won't be able to read all of them, but we'll make this available afterwards. Some of you don't know, Bill and I would occasionally, very rarely, just occasionally disagree over an issue. One of our favorite arguments, an argument that went on for years, centered around the issue of slow codes. Our arguments were intense and always polite, but it was clear that we differed fundamentally about the issue of slow codes. And finally, Bill had had his full of just verbal exchanges with me, and in 2011, he and John Lantos published two powerful, and I must say I'm rereading them pretty persuasive papers. One in the American Journal of Bioethics, and another in Acta Pediatrica on the topic, should the slow code be resuscitated, papers that I call to your attention. And speaking of resuscitation, it was Bill's work with Dr. Lantos, Jesse Hall, and an outstanding team of medical students, residents, fellows and faculty that Bill had assembled who resuscitated the fields of prognosis and prognostication. By using empirical data to resolve questions that previously had been examined without clinical evidence. For thousands of years, the diagnosis and prognosis were really all that physicians had to work with. Medical and surgical therapies were largely ineffective or outright harmful. But the savvy physician, I go back now thousands of years, who had seen cases like the one this patient had, could prognosticate. That is, could predict what the outcome of the disease might be. Traditionally, prognosis was less data driven than experience driven. Alvin Feinstein, a graduate of our college and our medical school, wrote in the 1980s that the most important clinical paper of the past 150 years was one on prognosis, published in the New England Journal of Medicine by Jacob Bigelow in 1835. A paper entitled on self-limited diseases. For Bigelow, the concept of a self-limited disease then created a large fertile area where diseases were not self-limited. And that allowed physicians to intervene to improve patient outcome. Feinstein has said that Bigelow in 1835 had revived the central concept of prognosis and in doing that had established a research agenda for medicine for the next 200 years. And then along comes Bill Meadows' work on prognosis only 160 years after Bigelow's publication. And Bill's work on neonatal ethics and prognosis extended the research agenda that Feinstein had referred to. Bill gathered data from many different sources to help establish prognosis in newborn infants. In 2008, he and John Lantos co-authored a book entitled Neonatal Bioethics, The Moral Challenges of Medical Innovation, a book that already is considered a classic in the field. Let me conclude by thanking Bill for all of us, for his great contributions to pediatrics and to neonatology, for his unsurpassed work as an inspiring teacher and mentor, and for changing the McLean Center and its programs. I now would like to introduce Dr. John Cunningham, the chair of the Department of Pediatrics. John. I'm proud of the University of Chicago and the Department of Pediatrics. I want to welcome you all here to honor our colleague, Dr. Bill Meadows. I decided when I came here today that I wouldn't wear a tie. Most of you who are in the Department of Pediatrics know that every event when I decided not to wear a tie today, to honor Bill. Because I don't think we know them with a tie, actually. So I decided that it was important that I honored him that way. I also decided not to discuss soccer, which he and I have discussed on many occasions. And unlike Mark, I don't have a picture to show you today. My favorite picture of Bill is walking down one of the corridors in Comer with an Ireland soccer scarf on. Seriously, I came to university approximately nine years ago. And during my interviews, I didn't meet Bill. But shortly after I started as a section chief here, I got to know Bill very well. I got to know Bill because the Department was in a period of a significant challenge. And as a co-section chief of the section of the Anatology, Bill would come to Section Chief's meetings where he would actually debate extremely strenuously about not only the need for strengthening the Anatology program and defending it, but also defending the Department of Pediatrics. In my view, as I contemplated what I was going to say here today, I would absolutely indicate that Bill is a small compass for our department. He provides us with the backbone and the rigor when we actually are thinking about every child. And I want to honor him by saying on behalf of my pediatric colleagues that Bill is a really important part of our lives. And I'm really honored to be here today to speak to his honor. Thank you, Bill. Thank you, Martin, John. Our first of the official best-drift speakers will be Professor Lainey Ross. The Caroline Matthew Boxquam Professor of Clinical Mental Ethics and Associate Director of the McLean Center. Lainey has written a number of books. She's probably the best-known voice of pediatric ethics throughout the country when my students in Kansas City heard that she's coming to give a thought here. They were going to say, Martin, can we touch the animal first? Sure. That's one of the most powerful voices back with the poor children and someone who has been fondly known by Bill for many years. Lainey, we've learned a lot. Welcome. But you are wrong. What a privilege to be invited to talk about my friend and colleague Bill and what he has done for neonatology and ethics, both locally and globally. Bill did the ethics fellowship in July 93 to May 94, and I arrived in July 94, so I get no credit and I take no responsibility for what he knows or doesn't know in ethics. Rather, I speak as a colleague and friend for over 20 years. Today I'm going to talk about three of Bill's most important contributions, his contributions at case conference to medicine in general and other contributions. So on the day I arrived, Diana Wu came racing into my clinic. She was wearing her bike helmet having just done a house call on a preemie who had been discharged from the hospital a few days ago. She wanted to make sure all new faculty were welcomed immediately and offered any help I needed navigating the university system. I could still use her help. What a wonderful colleague and networker she was. When she heard I was interested in ethics, she said, well, then you must meet Bill Meadow. Only a few weeks later I did meet Bill when we participated in ethics case conference. Bill arrived in W732, a room we have long since outgrown, about 10 minutes into a case discussion, wearing his cowboy hat and glasses hanging by a rainbow crokey. Greg Sacks stood at the front of the room. The case involved an elderly gentleman in his late 80s who was intubated on pressers unconscious with minimal prospect of clinical improvement and no prospect of neurological improvement. The question for the ethics team was to determine the appropriate course of action. The case involved the conflict between the healthcare team and the family. Greg wanted to follow the patient's wishes, which weren't fully clearly articulated but could be gleaned from his interactions with his primary care doctor. And Bill wanted to follow the wishes of the family. Greg was getting angry and angry that the patient's autonomous wishes were being ignored. Bill responded, I love you, Greg, but you're wrong. This would be a phrase I would hear many times myself as Bill and I butted heads in case conference time and time again. Bill eloquently explained that there were times that medical decisions were more about the family than the patient. I listened in fascination as Greg kept reverting to bioethical principles of autonomy, substituted judgment, and that the patient, not the family, should determine a patient's quality of life. And Bill defended his position based on intuition and emotions. This was a classic debate using Colberg principles and Carroll Gilligan's relationships. It was a debate about the proper aims of medicine, the dyadic doctor-patient relationship, and the family. Now, to be honest, I found Greg's arguments persuasive. And I'm glad that we did respect the old man's wishes, but we only did so after the ethics consult team had convinced the family that they wanted to follow his wishes. So in his own way, Greg did advocate for a family approach. The family, that is what Bill is about in ethics consultation and case conference and in life more broadly. How many times have you heard Bill introduce himself as Xander, Shmug, or Beanie's dad, or as Susan's husband? The family, it is the crux of Bill's approach to both pediatrics and ethics. And in pediatrics, Bill and I mainly actually do agree because pediatrics is not a dyadic patient-doctor relationship as classical bioethics teaches. Rather, pediatrics is a triadic relationship involving children, patients, and physicians, children, parents, and physicians. Bill and I agree that the central figure is the child. Now Bill's area of pediatrics is very specific, the premature or critically ill infant who cannot speak for him or herself. And so we rely on the parents to speak for him or her and to define his or her interests. Now it may surprise some of you, but who counts as a parent is more controversial than it may seem. And I'm not talking about IVF and surrogate moms or donated gametes. Rather in Illinois, the woman who gives birth to the child is the mother, unless she relinquishes her right. A man is the father only if he's married to the mother at the time of birth or if he signs the birth certificate, which he can only do if he agrees and the woman agrees. Now signing the birth certificate gives him parental rights and paternal responsibilities like paying child support. Many of our neonatal patients have only one legal parent, mom, although there may be many parental-like figures from dad to grandma at the bedside. And so mom is the only one who gets to make decisions for the baby. I hear Bill now, Laney, I love you, but. Bill does not approve of my focusing on legal parentage because what he really wants is to create a family consensus on what is in the child's interest. And I agree, that's ideal, but I do focus on legal parentage because it does and should impact on who has final authority. This is not to suggest that we should ignore the dad when available, nor should we ignore the grandparents, but it is to say when consensus cannot be reached and those are the cases that come to case conference, it is the legal parent or parents who have the responsibility to decide what is in the child's best interest. And it is the legal parent who gets to determine which other voices are heard. I think Bill and I agree that the legal parent shouldn't ignore all non-medical interests, nor should she ignore the interests and needs of other family members, but only to say that the child's medical interests are paramount even if other interests are legitimately considered. So I went and put Bill's name into Publisher Perish, an online scholarship assessment tool, and it gives you an H-index, which is an author-level metric that attempts to measure both the productivity and citation impact of a scholar's publications. It gives a G-index, which is an index for quantifying scientific productivity based on publication record and lots of other data that may or may not be useful. And here's what I learned. Bill's most cited article was entitled, Changes in Mortality for Extremely Low Birthweight Infants in the 1990s, Implications for Treatment Decisions and Resource Use. This article focuses on one of Bill's major contributions to neonatal ethics, and that is on the inaccuracy of prognostication, whereas we learned at CHOP, the Children's Hospital of Philadelphia, where we both trained about a decade apart, we learned never trust a creamy to follow any predictable pathway. Creamies will always surprise you. And Bill's data show that despite comments that neonatal intensive care or NICUs are expensive, they save a lot of lives and are a bargain when one looks at cost versus life year saved or quality of life year's gain. So we should acknowledge Bill as the premium advocate that he is fighting for their fair share of resources, which he did at Ethics Consult and as Dr. Cunningham suggested, he also did it often at pediatric faculty meetings. But Bill's advocacy doesn't stop when they leave the NICU and here Bill's contribution, while less well cited, is also very important. So here I wanna give a shout out to a second article, which I'll call Bill's most underappreciated article. Bill's work, like Diana Wu's work, engages the premium in the NICU follower clinic. Much less sexy work, less financial incentive than intensive care work and yet really important because graduates of neonatal intensive care units still have a lot of challenges to face. And so once again, a thanks to Bill the advocate who speaks for one of our most vulnerable populations, children who cannot speak for themselves, particularly for those whose parents have neither the resources nor the skills to fight for them in the public arena. Thank you, Bill. And then I wanna point out Bill's least cited article. Bill, we're glad you switched from piglet physiology to neonatal ethics. So let me ignore how an online impact factor metric evaluates Bill's work because there's a lot of controversy about their validity. Instead, let me share with you two other articles of Bill's, my favorite article and my least favorite article. So I'll start with my favorite article and it's entitled, ought standard care be the standard of care. In this article, Bill and colleagues examined when to start antibiotics in the emergency room for a child presumed to have a serious infection like meningitis. Bill and colleagues showed that at two premier pediatric institutions, unnamed in the city of Chicago, the median time until the initiation of antibiotics was two hours. And then he queried infectious disease physicians and emergency room docs and said, how long do you think it takes from the time a child presents until they get antibiotics? And the emergency room docs thought a median time of 46 minutes and the infectious disease docs thought a median time of 80 minutes. That is, both thought it took significantly shorter time than it actually did in the real world. So Bill and colleagues explain why this discrepancy is so important. When an outcome is bad and the family goes to court, the ethics, the experts will claim that the hospital failed to treat the patient according to quote standard of care because it took longer than what the experts would expect. Bill and colleagues argued that standard care should define standard of care. So why do I love this article? I assume that Bill researched this article after a thoughtful, careful colleague was sued for events beyond his or her control. And Bill is at heart a pragmatist. He's a practicing clinician in the real world where getting antibiotics can and usually does take longer than one might ideally hope. Bill concludes the article with this sentence, medical expert testimony that has no basis in reality ought not to be credited. So Bill advocates not only for premies but for his colleagues as well. We owe you another thank you, Bill. My least favorite article is Bill's work on the slow code. Now we all know what a code is from the myriad of TV programs in which patients almost die, they're resuscitated or coded, and at the end of the hour, they're back at home or at work resuming their normal life. Sad to say that's not how it works in real life. John Lantos was an author on a paper examining codes on TV versus codes in real life. In the study reported in the New England Journal of Medicine, researchers found that over three-quarters of patients receiving CPR on TV programs like Chicago Hope, ER and Rescue 9-11, they survived their immediate cardiac arrest and all but one survived with no long-term disability. In reality, fewer survive and even when they do, some die shortly thereafter or suffer permanent neurological damage caused by their disease or by the rescue effort itself. But the public knows that CPR is effective from their TV experience and so even when physicians explain that CPR will not be effective in your mother, flash sister, or cousin at this time, family members demand it. So what should we do? Bill and John offered three options. One, perform a full code that is messy, virtually always unsuccessful and leaves healthcare providers feeling moral distress. Two, override the family by getting an ethics and or a legal consult and ordering a unilateral do not attempt resuscitation order. Or three, provide a slow code, a symbolic gesture of a code without doing all the real heroics. That is, maybe do a few chest compressions, maybe give a round or two of meds, but do it slowly and stop it quickly. Bill and John support option three on the grounds that it gives the family what it wants but does not distress the healthcare providers. So they view it as a win-win. I disagree and I disagree strongly. I don't think the slow code respects anyone. The family has requested. No, they've demanded a full code because even if unlikely, it could work. They've demanded a full code, not a parody of a code. The physicians who are being asked to participate in a false code should be morally troubled by lying to the families and by causing any harm to the patient when the treatment is useless. I hear Bill saying once again, as just as if we are butting heads in case conference, Lainey, I love you, but you're wrong. Bill's other key contributions to the McLean program, the university at large and the wider hard park community is his role as a mentor. A large number of NICU fellows do the McLean Fellowship and do ethics research. Many co-authored with Bill. Pritzker Medical students work with Bill through the summer research program and again, many publish with Bill. Bill also mentors and collaborates with many peers at UFC around the country and as we will hear today from peers around the world. And it's not only pediatrics and neonatal ethics that Bill is a premier mentor, but it's also in his role as soccer coach, dad and friend. Bill is an effective mentor because he teaches by example. He always has a smile, a kind word, a supportive gesture. He's an effective mentor because he loves what he does. So I'm looking forward to hearing from the other speakers, many of whom who have worked closely with Bill clinically in the NICU and others who have collaborated with him in his research. For those who attended case conference, you have seen Lainey and Bill but heads a lot. On the note of butting heads, let me end with a final slide. I love you, Bill. I love you, Bill. No buts. I'm delved into these crucial studies with Dr. Meadow Moore as the afternoon goes on. So we're going to hold on a question for this one and introduce the next speaker, Tyler Grimes-Chisell, who was undergrad at University of Chicago, did some early research with Bill. And then I'm sure because of Bill's excellent mentorship, went on to complete residencies at Johns Hopkins University, after his child neurology and clinical and biochemical genetics. Now is at Vanderbilt University as vice chair of education in the Department of Peace. He's won numerous outstanding teacher awards but the most interesting thing that I found a book in New York online was your invited back to your high school to give the commencement address in 2002. It was surprising, right? Or good afternoon. Thank you, John, for organizing this. It's a pleasure to be here. And I'm gonna say, as John mentioned, I experienced working with Dr. Meadow as a college student. And so my comments are going to be based through the lens of a college student. And it was about 25 years ago. I started college when I was just finished third grade. And so it's really been fun for me to think back. It actually wasn't too difficult to come up with what I wanted to say because I actually have been repeating a lot of what you taught me since that time. So while working with him, and I'll tell you a little bit about the work that I did while I was a college student with him, I had the opportunity to go to the NICU and do rounds. And so I really think that at least this portion of the talk should be subtitled. This is a college student. Show him all the respect he deserves, which is none. And that's what he would say when there was a group of us actually, maybe three or four college students who were part of this early lab group. And we would go and NICU rounds and I literally knew absolutely nothing. And I remember saying, I feel so dumb. And he said, oh, you're not dumb. You're just ignorant. I'm like, okay, thanks for clarifying. So I graduated in 89 and shortly thereafter when I came to USC, I began working with him. So the work that we did that John mentioned was predicting survivability of extremely little birth weight infants. And the publication that we had several years later, I think it was in 2006, was basically saying that the best predictor of survivability was whether or not they were alive. And... But it got published. What was interesting is it was on Day of Life 4. So if you were alive at Day of Life 4, you were going to continue to live and you may be in the NICU for a long period of time, but those who passed away did so early on. And it meant that we should continue to invest in them. And so I think that that was a pretty cool experience. What it led to for me was after I went into residency in Baltimore, I became part of the Hopkins Ethics Committee. And I really believe a part of the reason I was selected as a resident was based on my experience with this publication and also with my experience working with Bill. And then I had the opportunity as a junior faculty member to be on the Ethics Committee for the Academy of Neurology. And again, I could write about my experience, not just the knowledge part that I learned in a lot of excellent courses here at USC, because I was a history and philosophy of science major, but also what applied ethics looked like in somebody who was a clinician. And so it had a long lasting impact on my career. But there were some other things that I learned as well along the way. One of them was work-life balance. We didn't call it work-life balance back then, but that's what you were modeling for me. I remember I think it would have probably been the lab school going to pick up your daughter and talking along the way. And I always saw how important family was to you. And that was really important for somebody who was going to have to learn how to manage the demands of medical school and residency and being a faculty member. And that was pretty awesome to see. I also learned about personal health maintenance. So I remember walking into the hospital one day and Dr. Meadow was passing me. He's like, oh, walk with me. Right, walk with me. It was more like run with you, right? And so I don't remember what the building was. Hannah Gray was the president. You had to go up to her office to drop something off. And it seemed like she was on the 13th floor somewhere. I don't know what floor it was. And so we go into the building and I'm looking for the elevator, but we took the stairs all the way up. Well, I'm covering all my textbooks. And we got to the top. I was still had a pulse and was breathing. And you went into the meeting and he's like, great. And I was completely out of breath. And I thought, this is really important. I'm going to have to be fit if I'm going to be a successful physician. So I knew it, walk with me. While I was fourth year in college, I got engaged, which was surprising to me, actually. That happened. And I remember you saying, you got married pretty young too. I was 22 at the time. My wife was, wife to be, was not quite 20. And so, whoa, right? And so you said to me, you're too young to get married. And I was like, how old were you? He's like, it was a different era. So the next time I saw you, I was working at a computer doing our, it was a retrospective chart review that we were working on. And you saw me and you said, yes, dear, yes, dear. I don't understand that. And then the next day, same thing. Instead of hello, it became yes, dear, yes, dear. It's like, you need to practice saying that. It's been the best marriage advice I've ever had. And it's worked. This is my family. So I have five children. My oldest is 17. That's Elise. Elise, Caleb, Moira, Justin, and Leah. And this is my wife. She looks like one of my kids here, but this is Teresa. Teresa says hi too. She remembers hearing about you when we were courting. And so she knows how much you meant as I was going through med school. And so she says hello too. All right, career advice. So I went to med school here at Rush and then I got into residency in Baltimore and I started getting really interested. I knew I was gonna be a child neurologist, but I started getting interested in metabolism and biochemistry. And I remember coming back, my wife's family is from Evanston and so we must've been visiting family and I stopped off in your office. And I said, you know, I think I wanna do genetics after I do neurology. And you said, what the? And then, why would anyone wanna do that? And so I was lamenting how much time that was gonna take me and what I remember you saying is Tyler, if it's what you love doing, who cares how much time it takes you to do it? And that's how you lived your life and how you did your work was, if you love what you're doing, and I could see that. And so I went into genetics and I work as a biochemical geneticist and child neurologist now and do a neurogenetic clinic. And I love what I do and I'm so glad that I didn't listen to a lot of people saying it's a lot of years and you're really gonna do that and you're gonna make less money than if you wouldn't do it, and which is all true. But it was really good. I also, again, I didn't know this at the time because I was just a college student, I really didn't know what rounds looked like. But when I started working in the NICU as an intern in pediatrics, I could reflect back on how you did rounds in the NICU and how the rest of the planet did rounds in the NICU. And it turns out you don't do rounds in the NICU by constantly walking from one bed to the other and never stopping. And I could remember the interns running after you, trying to get all the data points out before you had gotten to the next child. But when you did stop, it was, and I remember this case where you were there as well, we were in a circle talking about a baby in the NICU and doing ethics rounds in the NICU. And that was pretty awesome experience. So the data was not always as important. I think what you would say is I only want to know the data that's important as a resident that makes you very nervous because you don't really know what that is important. But the ethics part was pretty interesting to see modeled. You also had some interesting teaching strategies. So, John mentioned I'm now vice chair for education. I do a lot of teaching in the med school. I teach metabolism and genetics at the beginning of first year medical school and I teach from neurology and neuroanatomy. I'm involved in residency. And we're all about flipped classroom now and just in time learning and team-based learning. How do you engage the learner? And so there's one technique that's not really been utilized as broadly as you use that. But I remember one time you were asking, we were in our lab meeting and you were asking us questions and we didn't know the answers. And you were like, don't they teach you anything in university here anymore? I don't think they teach you anything. You don't learn anything. I guess I probably felt a little defensive because you had written on a chalkboard an equation. I remember what the equation was, but it wasn't balanced. And I felt a need to clarify that for you. So you turned around and you're like, what? And I'm like, Dr. Meadow, your equation is not balanced. To which you flipped me off actually during the lecture. I was fully engaged at the time. And so at the moment I was completely shocked. I mean, I'm a college student. I had never been treated like that. But in retrospect, I realized you saw me as a colleague. What I loved about being at USC was the passion and joy people have for critical thinking and really the creativity. And you modeled that amazingly well. Even as I look back, more so than a lot of physicians I've worked with, you know, a lot of medicine is now just doing, doing, doing. And I remember at one point, I think you broke your leg or something, you couldn't take a shower and you actually had to take a bath. You remember this? And you actually would say, you know, I was in the bathtub thinking. I was in the bathtub thinking. And it was neat to see that. And I now try to emulate that when I'm thinking of, taking a bath, right? Yeah, yeah, or shower, right? But I prefer walking. And it's been cool to think creatively about the work that I'm doing because I don't think that most physicians took the time or take the time to really sit and think and ponder. And you actually were very explicit about that and really emulated what this university stood for in a way that I could try to emulate myself. And so the last thing I wanna point out is you really relish your work. It's the best, it's the best word I could think of. You relish and just reveled in it. And it was all a part of what you did. And I was hoping whenever I was in college I could find a profession that I could have just embrace and revel in as much as you did. And I love my work. And I think what's particularly important to me is that it was never about you. It was about your work and about the preemies and their families. You were doing patient and family center care long before medicine actually called it that. But it was never about you. And I've worked with a lot of really successful physicians who ultimately try to make it about themselves. And I really respect you for that. And I think it's incredibly inspiring to be able to work with somebody like that. And I hope that when future physicians work with me they also recognize it's about the privilege of being a physician and taking care of other people's kids. It's not about us. And so thank you for modeling that for me. Thank you. Thank you. For over two for two speakers who did not go to their 10 minute panel. I'm sorry. Someday somebody might leave time for questions or comments from the audience but I'm not optimistic. I've been speakers of re-enters. Here you are, Brie. Brie is assistant professor of pediatrics right here at the University of Toronto and specializes in the care of all the complex infants both in the NICU and in the NICU. Follow-up of NICU studies and factors that have to do with long-term neuro-development, developmental outcome and has been a long-time student in front of that bill. Hi everyone. I really wanna talk about how Bill really thinks about opportunities for small babies. Small babies scare a lot of people. Not him. So this is the playbook for Bill Bentham. So my son. Barks, no. So my son's at the lab school and they have a new process. So they have a new process. You see thinking wonder about things that live in this PVC cube. And things start out a little bit esoteric and then your son wishes that Spider-Man was in this PVC cube. And he can think and see, think and wonder about it. And I don't know how effective it is for the four-year-olds but I really think it's something that I see in only a few important academics like Bill Meadow. So he sees things and wonders every day in the nursery. He does this every night with many emails. He does this every week in lab meetings. He does it at every conference with many others. He does it in every city at lunch or dinner but he prefers dim sum. So he really wants to ask the question and answer it, are premies worth it? I'll talk just quickly because he would want me to talk about this, about the money. Can't you just make a cutoff that decides? What do you know and when do you know it? What does time do for us? Why can't you just give parents the most that you can and about teaching your team the most that you can? So why are NICU resources considered scarce? To have NICU resources for all babies, you have to provide better care for all mothers. Most mothers are young and many are poor. Dedicating resources to an unknown person appears to be hard. In terms of numbers from perspective, which he's shown us many times, in the United States about four million babies are born each year, about three million people die. About 500,000 of these die in adult intensive care units. Amongst the babies that die, they're just about 24,000. So just in raw numbers, NICU resources are a small portion of health care resources. He's shown you this before. Our smallest babies, the ones that are the most vulnerable, the ones that are most in question are these 500 to 750 grand babies. They are comparable to our highest risk adult NICU patients. When you look at the columns, these are all the resources given to this group of babies. We only have about 20% of our health care resources spent on 80% of those that don't survive. You can see in the medical ICU, it's quite different. So the smallest babies are thought to cost so much, except for maybe they don't. Next, I'm gonna talk about this myth that they're so disabled. So a lot of people are nervous that we're resuscitating the smallest babies. When we look at the children with the most impairments, they come from the bigger gestational age groups. 45% of children with impairments coming out of our NICUs are 25 to 26 weeks at birth or 27 to 28 weeks. Even the 27 to 28 weeks, infants who are disabled or have impairments double the rate of the smallest ones. Then people say, well, aren't the smallest ones more disabled? Don't they have more problems? Well, actually no. The spectrum of outcomes is similar and you can see at the raw numbers there are still more babies that have the greatest impairments and the larger age groups because there are more of them, more of them survive. So maybe it shouldn't be about the resources. Let's assume you can decide based on prognosis. Dr. Singh really helped us. She looked back and asked neonatologists, what helps you decide about a baby? Whether we should press on. She surveyed thousands of neonatologists and a lot of people said, I wanna see how that baby looks in the delivery room. And we went a little further with that and we asked about apcar scores. Well, one minute apcar scores are lower than five minute apcar scores but no low apcar score precluded a good outcome and no high apcar score ensured a good one. And so this, seeing how the baby looks wasn't as such a good idea compared to some other things. We looked at physiology scores. They didn't help so much either. So then our field moved towards an epidemiology approach and we still wanna know more about the individual patient's trajectory but our field went differently. There are large cohorts of infants that have been studied through the NICHD and the pediatrics with the next group, we surveyed the neonatologists again about 65% of folks use these tools and many use them after birth, which they weren't designed for. And I'm gonna talk to you a little bit more about this. I think this data is coming a little too early. So this is what you can do. You can punch in the numbers for each infant. Were they 23 weeks? Were they 600 grams? Were they male or female? Were they singleton or multiple? And did they have steroids or not? And you can get an output. We compared outputs across different weight categories for the best case scenario and the worst case scenario and you can see the numbers are pretty varied. Imagine trying to explain these to each successive parent and you have to be right about the gestational age and the estimated birth weight. We think that's pretty hard. So Goldilocks is with her porridge. That's a little too hot, right? I don't know if I can make those decisions that early before the baby's born. What other data is available much later? This is where I live most of my life in NICU follow-up. We can accept at the time of discharge if you need oxygen, if you have ROP, if you have an adverse head ultrasound, that that child will have additional needs and the parents are ready to take them home. That may be too late. That may be too cold. So we wanna get in the shoes of each parent who will ask what will happen to my baby not 100 more or less similar babies but my baby. And so we built a framework. Build, build the framework that you should ask each clinician every day for each ventilated patient. Do you think this baby will survive to be discharged or die in the NICU? And if you pair the intuition of death before NICU discharge with adverse head ultrasound findings, you can predict both good and poor outcomes. This is when more data is available. So we took a cohort of infants born 22 to 25 weeks and we use this framework. This is a recent cohort. And when you have the best predictors, no adverse head ultrasound and no predictions of death before NICU discharge, at two weeks of life we can tell your parents about 70% of them will do well. And that if you have these adverse predictors, we're almost certain the child may die or may have neurologic impairments. And so this framework gives us more information. It's available later when you've met the baby, when you can give parents an assessment of their infant. Skip this. In terms of our prognosis perspectives, there are few areas of medicine where you cannot continuously adjust to prognosis. For the smallest babies, you may have to decide or you may be asked to decide as a parent before they're born what you wanna do. It's hard to go back. And we're saying that's really tricky. And that first decision begets other decisions. We offer a different approach for prognosis. And then you have to say to yourself, if I offer these parents this chance, can they adjust to the hardships of NICU care? Jessica, Lydia and Marin have really asked parents, what does the NICU experience do to you or for you? And they say that getting to know the baby can be positive, the infant can be seen as a fighter or a miracle. And that they have feelings of being grateful to have parented. So this time isn't necessarily miserable for them and the parents can get through it. So I wanna talk briefly about expanding the playbook. I'd like to start integrating multi-time point counseling for families with one dedicated team. Seeing how to get parents this important information different times and doing it effectively, we wanna ask parents and clinicians what's helpful when prognosis isn't certain or when prognosis might be poor. And I wanna talk a little bit about parent engagement. The picture on the right is of kind of an old-style NICU where they're incubators and they're caregivers but not many parents. If you see on the left, these are frames of a small baby with their parents continuously there. And that makes a difference for prematures. Their parents being comfortable at the bedside. So we wanna talk in my future work about engaging families. I've brought Yaya Ren back to the University of Chicago. She was here as an undergraduate and we're gonna try to electronically create rituals for parents and premies. We're calling it kind of intuitions 2.0. Cultivating meaningful infant-parent relationships pre- and post-discharge, facilitating parent-medical team partnerships and embedding developmental and play activities such that babies get from the, these twins get from the incubator to holding their own photo later. Pre-me and you will be founded shortly. It's been supported by the Bucks Bomb Institute. We are a soon-to-latch social benefit enterprise working to improve health and developmental outcomes for premature infants. We're using mobile technologies to help parents at the bedside adjust to what's happening to each, to their babies. Building easy, accessible online communication and interaction protocols. We wanna do this in NICUs around the world. Yaya Ren has experience in other countries as an anthropologist and we're gonna do our phase one assessments of the mobile technology in Comer and we have a collaboration in Chile. And our mission is to give every premie their best quality of life. So how does Bill make it just right? How does he make the porridge not too hot, not too cold? There's always a list. Everybody on the team contributes to the list of important work that needs to be done. New ideas can come at any moment and new ideas can be tested quickly but then they should be dealt with methodically. You find ways to support every member of your team and you don't give up on your team or your patients and parents. Thanks, boss. That was awesome. We're gonna take a quick 10 minute break or let's see.