Being a neonatologist and a mother [PODCAST]

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“Being a neonatologist and a mother is living with the knowledge that the question ‘What would you do?’ could so easily become real, not hypothetical.  And so what would I do? I don’t know, heartbroken mama. Because I feel too much, but I don’t feel enough. Because I know too well, but I don’t know at all. Being a neonatologist and a mother means sitting in those painful, fearful spaces of uncertainty, at a loss for what to say because I know that nothing I could ever say will be enough.

And so I just sit. In that space. With that other mother.”

Diana Montoya-Williams is a neonatologist.

She shares her story and discusses her KevinMD article, “Being a neonatologist and a mother.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Diana Montoya-Williams. She is a neonatologist, and she wrote the KevinMD article “Being a neonatologist and a mother.” Diana, welcome to the show.

Diana Montoya-Williams: Thank you so much for having me. This is quite the honor. I’ve been reading the articles for a while.

Kevin Pho: Well, thank you so much for your readership. I appreciate that. And we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Diana Montoya-Williams: Sure. So I am a neonatologist, and I work at a big children’s hospital in Philadelphia called Children’s Hospital Philadelphia. And I am really kind of an unusual neonatologist, is how I like to call myself, because I have lots of varying interests, many of which are not as common for other neonatologists to have.

So I’m obviously very, very drawn to taking care of babies within the context of their families and very interested in the maternal-infant dyad, so to speak, from a medical perspective. But also, I do a lot of perinatal health disparities research. So I’m very interested in why outcomes are different for certain mothers and their babies in this country and how that relates to their backgrounds, whether it’s their racial, ethnic background, or their cultural background, or their immigration background.

I love doing advocacy work around these issues and really trying to be involved in lots of different avenues pushing towards equity for children and their mothers in this country. So I wear lots of different hats: do some education, do some mentorship, do research, and legislative advocacy. So lots of different hats in my career.

Kevin Pho: So from a neonatology standpoint, what are some of the reasons that explain some of the health care disparities among the population that you see?

Diana Montoya-Williams: That’s a great question, and I really appreciate it. So I, like many others who study disparities, have really come to understand that the differences in outcomes that we see among some of our children that are born to mothers from historically underrepresented or underserved backgrounds, so for instance, Black, African American mothers, or Hispanic, Latinx families, or other families of color, perhaps families whose parents were not born in this country, we’re understanding more and more that the root cause of some of these differences in outcomes, and really preventable differences in the outcomes that we’re seeing in terms of preterm birth and low birth weight, are related to some structural differences in how people live in society and how people are treated in society.

Whether it’s how they access health care, how they access housing, how they access and interact with their physicians, and what conditions they live and work and play in, if they’re children. And so we know that a lot of those root causes are really structural, and they have, over time, discriminated and really created an uneven playing field for some of our families of color. And that manifests nowadays in what I see in my NICU, which is higher rates of preterm birth and low birth weight, and worse outcomes among my preterm babies among families of color.

Kevin Pho: And what are some of the things that we in the medical community can do to address some of the issues that you bring up?

Diana Montoya-Williams: Well, I’m glad that you brought that up. I love to talk about this, and especially, among other divisions, neonatology has really started to talk about what we as neonatologists can do to advance health equity among our babies, and more and more, how to be anti-racist. Because, like I mentioned, a lot of these root causes are related to structural forms of discrimination, like structural racism.

So one of the main things that I think we can do in every field, but definitely within neonatology, is just educate ourselves on the history of how this has happened and what continues to allow unequal and uneven playing fields to continue and to lead to disparate outcomes. And so really educating ourselves on the history of structural racism and the current, present reality of it. There’s a lot of great literature, lay and scientific, podcasts like Beats, and even videos. And so, lots that we can do ourselves, because we’re really educating the next generation of physicians, and there’s a lot that we can do if we understand that context.

Diversifying our workforce is a big thing, whether it’s who we accept into our medical schools, who we hire for residency and fellowship and faculty and leadership, and leadership outside of medicine, within health care. And so there’s lots that we can do in that respect as well.

And then the last thing that I really like to highlight is giving families and communities of color voice, whether that’s through research that’s really uplifting their voices and their experiences, or through QI work, quality improvement work, within clinical medicine that brings in the patient perspective. So lots of ways to uplift those voices.

Kevin Pho: Excellent. So let’s transition now into your KevinMD article, “Being a neonatologist and a mother.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Diana Montoya-Williams: Sure. It was an article that had been sort of percolating in my brain for many years, actually, and it started with my first pregnancy. So I have two little boys, a four-year-old and a one-year-old, but the first time I was pregnant, I was in my medical training. I was a neonatal fellow, and it was this very challenging, though beautiful, experience, but just really painful in terms of being in training while pregnant, while having a healthy pregnancy, and learning how to counsel and support families through very complicated pregnancies that often ended early, or ended kind of catastrophically, or at least having babies that were born way too soon, while being very pregnant myself, was this really unique kind of dichotomy to navigate.

So a lot of these feelings started with my first pregnancy, but this article came about after I’ve had my second baby. Now I’m a mother of two, and now I’m an attending. Now I’m the doctor in charge having these conversations with families and realizing lots and lots and lots of mothers who find out that I’m a mother ask me this question, like, “What would you do if this was your baby?”

And so drawing on all those experiences and my current realities of continuing to counsel parents in general, but especially mothers, through the most difficult decisions I’ll ever have to make, when their babies are facing life-threatening illness or complications, or deciding whether to continue aggressive resuscitation or intensive care, or switching paths to a more comfort-based palliative approach. Those conversations, and that continued feeling, caught in between being this mother who totally, somewhat, gets what pain they must be going through, but also doesn’t get it because my babies are healthy, that’s really where this article came from: all those human feelings as I did my job.

Kevin Pho: Can you share a specific story or example of that dichotomy you talked about during the time you were a fellow?

Diana Montoya-Williams: Yeah. I think during my time as a fellow, I was most impacted by the moms that I would counsel at the limits of viability. And so what that means in my field, at the time, was the moms who were in preterm labor, or whose pregnancy was threatening to end right at that 23-week gestation, meaning the pregnancy is only 23 weeks long, or maybe 22 weeks or 24 weeks, right at that limit of where we think, and at that time thought, that we could support babies and potentially that they could survive, albeit with many complications and high risk of complications later on.

And so that was really, I remember to this day very strongly, some of those counseling sessions, in the middle of the night, of course, because somehow everything becomes heightened in the middle of the night in medicine. But having these conversations about whether they wanted us to even try to resuscitate their baby, because the baby was going to be born so early and had such high risks of having such severe neurodevelopmental impairment that, you know, another option would be to just hold their very, very small, young infant, as opposed to having us aggressively resuscitate them.

And realizing in that moment that, by whatever stroke of luck, I wasn’t sitting in that bed, that this was just another woman with a pregnancy maybe the same length as mine, who was on a different, much more painful path, but recognizing that very little divides us, right? And I think in medicine, we have to find some sort of distance and divide from our patients to be able to do our job, especially when we face life or death so often, as we do in the ICU. But it was in those counseling moments during fellowship, and there are others now, where that distance for me completely evaporates, and I just feel that closing of that gap, for better or worse, right? It’s like a beautiful moment that I share with families, but it’s super painful for them, and it’s tough and challenging for me to this day.

Kevin Pho: We’re talking to Diana Montoya-Williams. She’s a neonatologist, and she wrote the KevinMD article “Being a neonatologist and a mother.” Diana, what do you feel are some of the challenges facing the field of neonatology going forward?

Diana Montoya-Williams: Great question. One of the things that I think we are starting to really need to come to grips with is how do we handle all the technologies that we are developing, and what is in every baby’s best interest? Because as we were just talking about the limits of viability, during training, that was pretty firmly at the 23-week mark. Well, now we are resuscitating down to 22 weeks, X number of years later, that I’m now not in training.

And so we are continuously expanding our research and our technologies and developing many different types of interventions, some of which are very aggressive or experimental. And, you know, I think a lot of us have lots of conversations amongst ourselves, but also within our own minds, about whether every therapy is warranted for every baby, whether every therapy and every aggressive intervention is in every baby’s best interest.

And so how we navigate that: We have all of these things at our disposal, but is it in this baby’s best interest to try this really aggressive thing, or to do this really aggressive intervention that’s still pretty experimental? Learning how to grapple with that and the ethics of that, and really listening to families as we do that, is something that I think we’re still learning how to do in neonatology.

Kevin Pho: And we’re speaking in mid-January, and I have to ask you a pandemic question. In terms of, from a neonatology standpoint, how is the pandemic affecting what you’re seeing in hospital?

Diana Montoya-Williams: It’s really interesting. I would say that the NICU has been kind of in a place that’s been sort of sheltered from the pandemic in many ways. So what we know so far, because I will say that everything pandemic-related is still very much knowledge in progress and evolving, but what we know so far is there doesn’t seem to be a lot of what we call vertical transmission of COVID, meaning when moms become sick with COVID, their babies are not being infected at high rates, as with other types of viruses or infections.

And so not a lot of babies are being born with COVID, which means my ICU doesn’t have COVID-positive babies, and we don’t see a lot of that. I mean, there are some babies who become positive, who test positive, and we haven’t seen a lot of significant complications from that. Mostly what we see is that babies are being born preterm because mom was sick with COVID. So she was sick herself, and pregnancy is a big challenge for moms’ bodies to begin with. And then when you add COVID and all the respiratory complications with COVID, sometimes we are ending pregnancies and doing C-sections or inducing labor to really save mom’s life and to protect mom’s health.

And so we’re seeing prematurity related to COVID, maybe, but babies, for some reason, are not being as affected as maybe one would expect from a really immunologically susceptible patient, which is good news for us. And so we do a lot of thinking and wondering whether everything that we see in the NICU, as far as babies who have respiratory issues, is this COVID? But by and large, it hasn’t been, and so we’ve been largely untouched.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Diana Montoya-Williams: Sure. I think it’s twofold. One is that doctors, you know, for all of our experiences and expertise and all of the big words that we use, we’re just people, like the patients that we’re taking care of, with all the really big, deep, complex emotions that humanity comes with. And so we’re just learning to grapple with that as we take care of patients.

But also, and especially, this is what I was hoping to convey in the article, is that we don’t always have all the answers. But, you know, I think when we’re trying to do our best, and when we’re doing our best, we’re just sitting in that space of uncertainty with you and being really transparent about what we do know and what we think and what we would do as humans, as parents, and as physicians, and really sharing in that uncertainty with our patients and their families.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Diana Montoya-Williams: Absolutely. Thank you so much for having me.

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