adpi_med said:
anyone read the recent article in JAMA about the long term followup of the micropreemies?
just curious about some opinions.
i'm seriously considering a career in neonatology, and this issue is the main reason holding me back. any thoughts, especially oldbearprofessor?
Always nice to be on SDN speed-dial
The JAMA article is from the major group in the US that has done long-term follow-up. Their data, as always, is excellent and fundamentally is consistent with previous data. In general, there is an about 20% incidence of significant handicap (severe visual, cognitive or motor problems) in surviving infants < 1000 g birthweight and at least a 50% incidence of problems such as attention deficit and learning disorders. Interestingly, the data on long-term quality of life is mixed with a somewhat positive outlook in young adulthood based on Saroj Saigal's data. I encourage those on SDN who wish to delve into this issue to do a pubmed search on Saigal and Maureen Hack and read at least the abstracts of some of their research. With that as a basis, then issues such as "who can/should/must be resuscitated and cared for in an NICU?" can be rationally discussed. It is worthwhile having a talk with some practicing neonatologists in your area regarding their perception of these issues from a legal issue as well. Opinions on this vary considerably in different parts of the US and the world.
However, with that in mind, I think your real question (or at least the one I wish to approach on SDN) isn't "who do we take care of?" but "is neonatology a career that is worth going into given the bad outcomes for many babies?"
Clearly, this question can be asked of many careers in medicine - especially any that involve critical care medicine where outcomes, at any age, are often not great. In the end, neonatology as a clinical career has its ups and downs with regard to how we feel about the patients for whom we care. Some patients who are very sick, such as premies > 1500 g with HMD and full-term babies with pulmonary hypertension, will usually do well, and as such are "feel-good" cases. Others, have a poor outcome regardless of intervention (congenital anomalies such as Potter's Sequence for example) and tend to be difficult in terms of family interactions, but not that difficult to deal with, because, after all, there wasn't much that could be done anyway.
That leaves two or three especially tough groups to deal with. One is the baby < 1000 g, especially < 750 g and 24 weeks gestation and the other is the baby with a problem like moderate or severe perinatal depression. We ultimately know that the outcome is both uncertain for such babies and that often times care is very frustrating.
Only with time can you decide if this is worth it - after all, many such babies do very well and are rewarding to care for - I still keep in contact with kids who were < 750 g at birth who are now in college and doing quite well. Othertimes, it isn't so much fun or very rewarding. Residency is not necessarily the ideal time to think about this - sometimes the perspective of the stressed intern isn't as positive about things as they might be.
One way I like to look at things is to consider "why" we still have long-termdevelopmental problems in small babies even in an era of surfactant, etc. I think that at least SOME of it is related to issues of nutrition, care-giving atmosphere, etc that can be addressed and improved.
In the end, think about how you like doing the things that neonatologists do as a career. That includes the "fun" stuff, like procedures, but also the less than fun stuff like counseling families that it is hopeless and what that means. In the end, I enjoy it because I mix clinical and research (and a bit of teaching here and there). I don't expect and never expected that clinical medicine would be all "fun" or "satisfying", but when looked at as a whole career, I've loved neonatology and never considered anything else after my sub-I as a 4th yr med student so very, very long-ago
Fundamentally, I enjoy working with babies, the team atmosphere of care that exists in an NICU, and the state-of-the art medicine. These have not and are not going to change in this field.
Hope this has helped
Regards
OBP
