History has taught medicine some brutal lessons. Nearly two centuries ago, Ignaz Semmelweis noted a disturbing pattern in the maternity wards of Vienna, Austria. Women cared for by physicians were dying of puerperal fever at dramatically higher rates than those cared for by midwives. The hospital still looked functional, the wards remained open, physicians continued working, and the institution carried on. But something inside the system was profoundly wrong. Semmelweis eventually showed that a simple behavioral change, physicians washing their hands before examining laboring women, could dramatically reduce maternal mortality.
How many women died before his colleagues were willing to understand, believe, and act? Medicine has changed enormously since the 1800s. Unfortunately, our ability to dismiss uncomfortable warning signs has not. There is even a phrase associated with this tendency, the “Semmelweis reflex,” the instinctive rejection of new concepts because they conflict with established beliefs or norms.
In 2026, our entire team of nine neonatologists was terminated. The neonatal intensive care unit (NICU) stayed open with the schedule filled through a new contract using temporary locum tenens neonatologists and neonatal nurse practitioners. So what, exactly, was lost?
A NICU is an entire clinical ecosystem, not just beds, machines, credentials, and names on a schedule. It is the nurse and respiratory therapist who already know how an attending communicates when a 23-week periviable infant is emergently delivered. It is the neonatologist with two simultaneous transport requests who knows which referral hospital can safely stabilize one critically ill infant while sending the transport team for the baby who cannot wait. It is a group of physicians interpreting emerging evidence through the lens of their own population and community resources, changing a guideline, and then monitoring outcomes closely enough to know whether that change actually helped. It is the pharmacists who know the physicians well enough to say, “We need a better protocol for pressor drips at 2 a.m.,” and then work with them to build one.
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This infrastructure does not appear on an administrative staffing spreadsheet. This is not an argument against locum tenens physicians, many of whom are outstanding clinicians and essential in many rural health systems. Nor is this an argument that medical groups should never change. The warning is bigger. What happened in our southern Oregon community hospital is not occurring in isolation. In Fresno, one of California’s largest nonprofit health systems turned hospitalist staffing over to Sound Physicians, a national company backed by private equity and OptumHealth. Elsewhere in Oregon, a 35-year emergency physician group nearly met the same fate until nurses, physicians, and the community pushed back, including through legal action. In Virginia and West Virginia, another independent emergency medicine group was replaced across six hospitals. These are not isolated employment disputes; they are warning signs of a broader restructuring of who controls the clinical workforce.
The deeper question is what happens when health systems begin treating experienced clinical teams as interchangeable labor. Physicians remain ultimately responsible for patient outcomes, yet we have a diminishing voice over the systems that shape those outcomes. That is the warning. Our NICU is another canary deeper in the coal mine.
Across the country, physicians are watching decisions about staffing, restructuring, consolidation, and outsourcing move increasingly beyond their control. The administrators making those decisions have likely never seen a NICU team carefully position a ventilated 500-gram infant so a mother can hold her baby for the first time. They may never have watched an exceptional NICU team move almost wordlessly through a code because everyone knows the next step. And they may never see the difference between a schedule that is full and a clinical system that is stable.
Physicians do.
And that creates an obligation to speak. Who controls major clinical decisions in your hospital? If a decision threatens quality of care, is there a meaningful route to raise those concerns beyond the same administrative structure making the decision? Do you know who sits on the board of your hospital, and can you actually reach them? What protections exist when clinicians voice concerns about business decisions that detrimentally reshape patient care? What role does the medical staff have when an entire clinical service is restructured despite concerns from physicians working within it?
Our advocacy did not end when our employment did. I am not asking physicians to care because nine doctors lost their jobs. Patient advocacy is not separate from good clinical care; it is part of protecting the conditions that make exceptional patient care possible. Hospitals exist to serve communities, yet major decisions affecting infrastructure are treated internally as solely business decisions. The public sees an open NICU, an open emergency department, or a staffed hospital and reasonably assumes nothing fundamental has changed.
Neonatologists, especially, understand early warning signs. We know the significance of the third apnea event in a 30-week infant who had a central line a week ago. The monitor may look fine and the baby may look comfortable between events, but something has changed, and experience tells us not to wait for the crisis before investigating. Health care systems have warning signs too. Loss of physician voice is one of them.
A hospital can remain open while its clinical infrastructure quietly erodes. A schedule can remain full thanks to capable locum clinicians, while institutional knowledge, continuity, relationships, and years of local outcomes experience disappear. A service line can look intact from the outside, while the physicians who built it no longer have a seat at the table.
The canary in the NICU is no longer singing a comforting song. It is eerily warning us. The question is whether we listen before the next physician team disappears.
Shelly Haug Monti is triple board-certified in pediatrics, neonatal-perinatal medicine, and hospice and palliative medicine, with additional expertise in pediatric bioethics. She has cared for critically ill newborns across community and regional neonatal intensive care units and is active in physician advocacy focused on patient safety, clinical continuity, transparency, and preserving physician voice in hospital decision-making.
She is a cofounder of Babies First Southern Oregon, a physician-led advocacy group working with families, nurses, community members, and state legislators to strengthen neonatal care and hospital accountability.
Outside medicine, she is a mountaineer and polar endurance athlete pursuing the highest peaks on each continent. These experiences have reinforced her belief in preparation, teamwork, and speaking up early when conditions begin to change. She shares updates on LinkedIn.
