On the Incubation of a Professional
By Eric Horowitz, MD, MHA, RD, FAAP
“NICU parents: the strongest people you never wanted to be.” – Unknown
There is no ‘right’ answer, just the path taken – some musing of a neonatologist.
When people talk about medicine, one often thinks of the science that informs the art of navigating the complexities that is human health within the gray of no absolutes. From this idea I often reflect on the notion that there is no such thing as a bad thing, just too much of a good thing. And I will ask you to ponder what this means to you as I share my following musings.
To begin, I have found over the years, that when speaking with the families of my patients, it is often best to introduce myself and make sure we share a joint understanding of what is going on with their child. In fact, during consultations, I ask if families even know what a neonatologist is, and why one might be here to speak with them.
So please allow me to do the same for you. All of us are many things. Some of the things I identify as, a father, husband, researcher, gardener, friend, and neonatologist. A neonatologist is a pediatrician with an extra three years of training in critical care for children under one year of age (infants). Neonatologists often first become involved with the care of families when a member of the birthing team has a concern that an infant may require additional help after they are born. Needs that may require special attention due to prematurity, genetic or metabolic conditions, anatomic concerns, impacts on the child from the medical concerns or care of the mother, or when something unexpected urgently declares itself.
These can be stressful times for families and healthcare providers, alike. Moments that can leave permanent marks on who we are, and who we wish to be. Marks on the dreams we have for ourselves, and the dreams we have for those around us. It is the uncertainty of what is to come that causes stress. In medicine, we all struggle with how to best navigate these uncertainties, even as we are guided by the certainties, we believe to be true.
“So why does a neonatologist share this story? As a neonatologist, I provide care for those most fragile in our society, and who are just beginning their lives. Lives with many unknowns and a myriad of potential futures yet to be written. In the moments when a child needs my care, the decisions made can have profound impacts on their future. ”
As a pediatrician in training, I was first struck by this concept when I was on a week of night calls. A week with frequent admissions from the emergency department to the pediatric floor in a very busy children’s hospital. One evening, I went down to the emergency department to admit a tween who was non-verbal, in a wheelchair due to severe cerebral palsy, and being admitted for complications of his complex care needs. This was a child of a divorced mother who was exhausted, stressed, and drained. A mother slumped in a chair and accompanied by another child. A teenager, with teen angst, but compounded by overt hostility to the situation, the mother, and the sibling.
While this family’s dynamic left me saddened, I felt I understood it. This child demanded a lot from those around them. A lot financially, socially, emotionally, and temporally. And in that moment, to me, it seemed to make sense. The stress they had to bear, broke this family.
In medicine, advice often given is that once you think you know it all, mother nature will reach out and show you how wrong you are. And not two nights later, she did that to me.
Again, on nights with many admissions from the emergency department, I again was admitting a tween for complications of their complex care who was non-verbal and in a wheelchair for severe cerebral palsy. Again, a child of a divorced and stressed mother, who brought along the teenage sibling. But where the grunts and groans of the previous child were uninterruptable to those around, these guttural noises were their own language to this family. A family with a mother curling up and spooning her child, rubbing his back, and explaining to us what he was communicating. The teen sibling attending to them both, by carrying needed supplies, bringing them a glass of water, and wearing an expression of deep concern for their sibling.
If one read the medical history of these two families, the medical course was similar, but the outcomes, at least in that moment, were very different…to me.
So why does a neonatologist share this story? As a neonatologist, I provide care for those most fragile in our society, and who are just beginning their lives. Lives with many unknowns and a myriad of potential futures yet to be written. In the moments when a child needs my care, the decisions made can have profound impacts on their future. Futures that may end in death or profound disability that never allows the child to live independently, or futures of independence and possibility, but coexisting with varied intellectual, physical, or emotional disabilities, or the futures that many parents hope for when they first learn that they are bringing a child into the world.
To help navigate these potential futures, neonatology has come a long way since it began as a specialty. Many feel that neonatology began with the death of Patrick Bouvier Kennedy on August 9th, 1963. This was the child of JFK, who was born at 34-weeks gestation, but died at a few days of age from respiratory failure related to prematurity. This was a time when approximately 1.8% of all newborns died within the first month of life. In fact, a two-pound child born in the 1960’s had about a 95% chance of death, but by the early 2000’s such a child had over a 95% chance of survival. Today, we push the envelope even further for those far younger or with ever increasingly complex conditions. But survival comes in many different shapes and with different futures.
With critical research vetted by peer review, repeated exploration, and public scrutiny, we continue to expand the capabilities of the care that we can provide. Care that forces us to work with families to balance doing for the child and not to the child. These improvement and research efforts, however, rely on essential support from government and foundation funding. Funding that allows for impartial and critical exploration of science, while minimizing the potential influence and bias of external agents. Such funding mechanisms are now uniquely changing, as we shift in our approach to research.
Just as critical research adapts to the changing world, the mechanisms to fund the care pediatricians provide also needs to evolve. It needs to evolve because pediatric care is paid for, in a very large part, by Medicaid. In fact, 42% of people enrolled in Medicaid are children. As Medicaid pays for 41% of births and provides medical insurance for 45% of all US children (or ~33 million children), its role in assuring the health of our children in our current healthcare environment cannot be understated. Further, among children with special healthcare needs, Medicaid is again the single largest source of insurance, covering 45% of children with special healthcare needs (or ~7 million children). Such broad reaching healthcare coverage is essential for families and their children.
I toil every day to help those around me achieve their brightest futures. We all worry about our personal needs, and how to take the best care of ourselves. But where is the balance of good intentions before they go too far, and become too much of a good thing… and begin to harm others?
Now I will go back to saving lives, comforting families, supporting colleagues, advocating for children and my profession, and spending time with my family. I hope as you read this, you think about how you are making this a better world for the children around us. Life is a team sport, and one made better by great teammates.
About the Author
Dr. Eric Horowitz is a neonatologist in Massachusetts. He completed his medical studies at SUNY Upstate Medical University, pediatric residency at the Children’s Hospital of Pittsburgh, and fellowship a Duke University Medical Center. In addition to this training, he also completed his Master’s Degree in Healthcare Administration from the Gillings School of Global Public Health at the University of North Carolina – Chapel Hill in 2016 and was inducted into the Delta Omega Honor Society for Public Health. During his over 15-year clinical career, he has worked in academic, corporate, and private group practices covering military, rural, and urban NICUs. He has passion for the field of neonatology and strives to help children find a brighter future and their families to navigate the challenging paths before them.