Graduate Nicole Yamada, MD, (Class of 2015) speaks with our Division's science writer Laura Hedli about her experience in Stanford's Neonatal-Perinatal Medicine Fellowship Program. Dr. Yamada is now a clinical associate professor in our Division. She is the Medical Director of the Neonatal Critical Care Transport Team at Lucile Packard Children's Hospital Stanford and the Associate Director of the Center for Advanced Pediatric and Perinatal Education. 

Laura Hedli [LH]: Why did you choose to pursue a fellowship in neonatology?

Nicole Yamada [NY]: I really like taking care of babies, their physiology, and practicing fast-paced medicine. But the thing that was more unique to me was taking care of the family unit as a whole. No parent really expects to be in the NICU after her baby is born.

My personal interest is the difficult conversations: talking with parents about how sick their child is, or the fact that their child is dying, or the fact that we think it’s time for them to transition to comfort care. Those hard conversations are really challenging to do well. My own personal goal and interest is in learning how to do that well and how to help families have the best possible experience while going through such a difficult time.

LH: Why Stanford?

NY: The main thing that attracted me to this program was the opportunity to work with Dr. Lou Halamek in simulation-based research. Having someone in simulation who is also in neonatology is not a common resource from what I found during my fellowship interview process.

LH: What got you interested in simulation-based research?

NY: We did a lot of simulation-based training in neonatal resuscitation during my residency program. I became curious about how I could use simulation to improve performance in the delivery room. While I learned some basic skills in residency, I wanted to do more as far as improving human performance during newborn resuscitation.

LH: Your fellowship research is focused on using simulation to improve communication. Explain.

NY: I’m looking at communication between the different members of the team that are in the delivery room when a baby is being resuscitated. Can you standardize that communication and make it more concise so that people will make fewer errors during a resuscitation?

I’m using simulation to do research that one couldn’t otherwise do in a real clinical environment. It’s much harder to get a study done that involves real patients because then there’s risk to actual human life. Simulation-based research also allows us to standardize things a lot more than we would be able to in a [real] clinical environment. In my study, every person who came through did the exact same two clinical scenarios. All the vitals were exactly the same. All the equipment and where it was located and how it was set up was exactly the same. This took away a number of clinical variables, so that I could really isolate human behavior in response to my intervention.

LH: Where are you with your research now?

NY: I’ve completed my study and data analysis, and I have submitted a manuscript for publication; I’m awaiting response from the journal. In October, I gave oral presentations at two different sessions of the American Academy of Pediatrics (AAP) National Conference & Exhibition: The Neonatal Resuscitation Program (NRP) Steering Committee and the Perinatal Section of the AAP. In January, I presented a poster at the International Meeting on Simulation in Healthcare. I have been accepted to give an oral presentation at the Human Factors and Ergonomics in Healthcare meeting, and I have abstracts submitted to Pediatric Academic Societies and the International Pediatric Simulation Symposia and Workshops.

LH: What are the major findings?

NY: I was able to show a trend of improvement in the primary outcome, which was a decrease in overall error rate. This meant that subjects adhered to the NRP algorithm better when they were exposed to a standardized resuscitation lexicon. They also decreased the time to starting positive pressure ventilation, which is breathing for the baby, and they decreased the time to starting chest compressions. This was an improvement on retrospective data I reviewed regarding how people performed in the [real] delivery room, where I found that providers are routinely late on starting positive pressure ventilation and chest compressions compared to when the algorithm says they should be starting. The next step will be to run a larger study with a larger sample size so that I can hopefully show statistical significance.

LH: Dr. Halamek was your mentor on this project. What was that like?

NY: I started talking to Lou about my research plans soon after I matched, while I was still in residency. That was very helpful because he was able to get me started on thinking about what I wanted to investigate. He’d say: “What’s interesting to you? What’s your question?” Once I answered, he said: “OK, if that’s your question, now you design the study.”

He’s always been very available and willing to help his fellows [Janene Fuerch and I] with whatever we needed for our research, while also giving us the independence to design and direct our own project.  

In addition, Lou has been a fantastic career mentor for me as well, especially now that I’m in the phase of looking for jobs and thinking about where I’m going to be for the next stage of my career.

LH: How have you balanced your clinical responsibilities with your research?

NY: At every stage of our careers up until now – during residency training and med school – somebody always expects you to be somewhere at a certain time, and you have patient care responsibilities every day. In this fellowship, it’s more freeform. You are allowed to organize your time however works for you, but at the same time, you have to be disciplined about it. The longest stretch of clinical time we have is when we are on service blocks, which are 14 days in a row.  Clinical service time is scattered throughout the fellowship training years, with the greatest amount in the first year and then gradually decreasing after that.  The rest of the time is research time, but we still take overnight calls once or twice a week. People work in their research time around their calls and their service.

LH: What should fellowship candidates and incoming fellows know about moving to the Bay Area?

NY: The biggest thing people will experience is sticker shock given the cost of living out here. That said, I think it’s definitely doable on a fellow’s salary.

The weather is amazing. It’s usually sunny. We still get rain in the winter, but we don’t get the fog that San Francisco gets, which is nice, because that fog depresses me.

LH: Is there anything else that you would want to add about the experience that you think incoming fellows should know?

NY: One of the concerns I had coming into this program was: Am I going to get enough clinical experience? If you look at our numbers, we have a lot less clinical service weeks than some other programs out there.

But the difference is, when we’re in the unit, we’re taking care of really sick kids. Our unit is 40 beds, but it’s all level III/level IV babies, which makes our clinical experience really valuable but intense. At other institutions, they can have 40 beds, but half of those beds are the level II babies. So, you’re only taking care of 20 or 18 sick kids. Here, you get a lot more exposure anytime you’re in the unit to a lot of different pathophysiology and at high acuity.

LH: Since you’re taking care of all level III/level IV babies, the learning curve must be quite steep.  

NY: It can be, but the attendings here are really supportive. I’ve never had an attending question why I called them in the middle of the night. On service, they are able to really support you, especially in that first year. They know that the unit can be overwhelming because of the acuity.

The other thing is we don’t have attendings in-house. Not all programs have that. For us, that’s a good learning opportunity as well, because you’re in the unit essentially by yourself. You have nurse practitioners, but you don’t have an attending. I’ve learned a lot from our nurse practitioners, but I’ve also really learned overnight: What is my comfort level? What do I know? How do I figure out when I need help? And what are the things where I can really push myself, to manage on my own? Not having attendings in-house was something I wanted for my fellowship training, because I wanted that challenge to help me develop my clinical skills and decision-making.