A Festschrift in Honor of Bill Meadow: Part 3 of 3

Eduard Verhagen

If you speak not as a first speaker like I do, some of what I've used in my slides may sound vaguely familiar, but it doesn't matter. Dear audience, Bill, Susan, family, and friends, I am very honored to be standing here to talk about Bill-related projects. Working with Bill made me copy his black and white PowerPoint presentation style. Verdana, size 36 at least, with whole sentences spelled out which help you in case you're nervous and forgot what you wanted to say.

Eduard Verhagen

That is only a small part of what I learned from Bill and what I did with Bill, and I'm going to tell you a bit more about that. And I thought of predictions and facts because those are the two main elements that I learned and that I started developing myself in, and Bill helped me doing that. A feestschrift is almost Dutch. We would say feestschrift. Groningen is in Holland, in the Netherlands, and it's up north. This is our hospital. And I'm not going to tell you much about it. If you like, you can come and visit us, just like Bill did. And when he taught our residents, when he gave his presentations, I think the same thing happened That happens to many of you and other people that have witnessed his talks. They're almost drooling and they're provoked and they start thinking about things that they took for granted. It was excellent. But let's talk about soccer.

Eduard Verhagen

This is the famous Dutch team. They were not predicted to become European champions in 1988, but they did. They had some great players, but one way or the other, they didn't get great results in the national team. So individually, they were good, but as a team, they couldn't really find it until that tournament when they became champions. Ruud Gelid, you all recognize him. Can I point it out now? The guy on the left. And then, of course, Marco van Basten, all familiar names for Bill because they found out He knows a lot about Dutch soccer. He sometimes knows even more than me or my kids. It's amazing.

Eduard Verhagen

This is Bente. Bente is a girl who was born in 2001, a bit south from Groningen and she was referred to us because she had blistering disease and the referring pediatrician wanted to know what our diagnosis would be. she came to the university medical center and she turned out to have a severe very severe form of epidermolysis bullosa it's a disease that in its severest form causes excruciating pain skin infections and early death so the parents came up to us and said please could you end the life of our child we did some searching on the internet and we have found out that our child has nothing good to expect from life other than pain and suffering and we don't want that so we agreed with that prediction and the prognosis was really poor quality of life the expected quality of life was very poor But there was legal uncertainty. Even in Holland, where euthanasia for adults was allowed, there was great legal uncertainty. So nobody was brave enough to really do the euthanasia. We discharged the child to a referring hospital, where she died three months later.

Eduard Verhagen

uh... when we heard that decided that that wasn't great medicine that we practice so we made a protocol locally first for our own hospital in case we would see another bent it for termination of life in stable newborns with sustained suffering in situations where no life sustaining therapies are left to withdraw we did this because we wanted to regulate the existing practice of newborn euthanasia and make it more transparent. We knew it was going on, and we wanted to make it more transparent. And we wanted to promote reporting and public review of all cases. This was legally a

Eduard Verhagen

must, but it wasn't maybe done in all cases. So that was the Groningen Protocol. was portrayed in the Dutch media in August 2004. It didn't do much. There was a transmission about parents who suffocated their own children with cushion because of the severe suffering that they couldn't stand. And I was telling in the same program about a protocol that we made for severe cases. It didn't do much in Holland, but it was seen by journalists in Belgium who wrote for journals in Spain and in Italy, and then it got viral, as we say now, but we didn't say it like that then. And it really got explosive when the Vatican started to get involved. The lower picture is of the Osservatore Romano,

Eduard Verhagen

which is the Vatican's newspaper. who said basically that Verhagen was a person even worse than the Nazis in the Second World War. That got the attention of many other international media, so it wasn't a pleasant time for Groningen and it was even worse for me. We tried to inform the professionals by writing about why and how and telling a bit more about the context of of the protocol in the Dutch legal and social system, but it was difficult. And at that time, when things were at its worst, I think, there was a guy in a conference in Toronto that I didn't know who was chairing a session of clinical ethics, and there was an emotional and interesting discussion about the end of life, specifically the protocol. And this was, of course, Bill Meadow. After the session, he came up to me. He started talking. He was genuinely interested in the protocol, and he was genuinely interested in me, which was

Eduard Verhagen

very important for me to find out that people at conferences were interested in you. So he said, let's do a research project. And there are many questions to be answered. For instance, the Dutch babies, are they different from the Chicago babies? We should try to find out. Are our doctors maybe different? The nurses, the parents, is it something else that explains why you're doing what you're doing? How actually do babies die? What do we know about it? We should do a cross-cultural comparison, and that is what we did. And we published about it. So we got a few people together, and most of them are in the room. we set up a a model that we could use to more or less similarly compare babies in all those units and see how decision making was different and the model was based on physiology stable or unstable and the intervention of withdrawing or not withdrawing life supportive treatment And so this is what we found. We found that there were similarities in withdrawing and withholding

Eduard Verhagen

lifesaving interventions in Groningen, Montreal, and Milwaukee. And Chicago really stood out. They never stopped the ventilator because of quality of life considerations, whereas the others did this in around 30% to 50% of cases. So a lot of babies that died did not die because we couldn't save them. They died because we chose, electively, to extubate them. And it was through this research that we got to the details of it. And we published it and got a lot of comments about it. Our conclusions, and you may recognize the bill type of formulating is our approach is a better description of death and dying in the NICU than has previously been available. We believe in it and others too. Almost all NICU deaths are accompanied by some degree of withholding or withdrawing, but the physiology, physiologic stability of dying infants varies within countries and between countries.

Eduard Verhagen

Cross-cultural comparison in end-of-life practice is feasible and important when comparing outcomes between NICUs. And I think this is one of the key messages that we kept on repeating. It is possible to compare and it's important to compare if you want to understand outcomes. We did also look at the use of comfort medication in dying infants and

Eduard Verhagen

We wanted to clarify comfort medication use and neuromuscular blocker use in different NICUs. And we found a lot of similarities. We found, for instance, that no babies who died in the delivery room received any comfort medications. And we tried to speculate on reasons why. We found that most infants dying in NICUs received some comfort medications during the 48 hours before extubation.

Eduard Verhagen

And we also found a lot of differences in type and dose of comfort medication, the policy of initiating or increasing medication, and the use of paralyzing agents. And this is just an example that shows that, for instance, after extubation for quality of life reasons, in some units, medication, comfort medication is increased, but not in all. And so there are huge differences between units. And you don't know until you start gathering the data.

Eduard Verhagen

So we concluded that given that dying babies tend to look alike, independent of their geography, we speculate that other concerns like legal, norms, values may have influenced the physicians. We may be treating more than the baby with these palliative medication efforts. When you do international research like Bill does, it is imperative that you go to those units and countries and find out who's working there, what their families are like. So Bill visited us several times, and it was always a joy. He taught our residents a lot of things, and I'm very happy that he did, and we still profit from it. And of course, you need to go abroad sometimes. This is Geneva. You may recognize a lot of people on this slide, where Annie organized for us to reflect on ethical issues in luxurious surroundings. And you can see that Bill enjoys this. We did too.

Eduard Verhagen

What happened afterwards? Well, we continued. writing papers of the continuing importance of how babies die. And even today we are still using the same model to compare decision-making and outcomes in units around the world. This is from people in Sao Paulo who approached me and asked us if they could compare their decision-making to ours. And we use this model and we're going to publish it soon. So it's still I think it started with Bill finding me in Toronto and helping me

Eduard Verhagen

finding the joy in getting those data. I think I might say that even our practice in our country has changed a bit. We used to be very

Eduard Verhagen

early with our predictions in the NICU. withdraw life support of treatment very early. But that has changed. We take the time now to do more interventions and find out really what the individual baby can do and what the parents want us to do. So this has really changed our practice and it will change even more. I even persuaded Bill in 2012 to do a prediction

Eduard Verhagen

about the Dutch soccer team because they were playing again great we had some super players and I was convinced that we would again become European champions and as a token of that I offered Bill this scarf just to celebrate the coming championship however Bill was hesitant in his prediction he said it's easier to predict what will happen once the tournament has started And after the first games have been played, you might want to come back and I'll make a prediction, but not beforehand. And he was right. We played a terrible tournament. And so we were all very unhappy. I learned a lot from that from Bill. And I used the soccer knowledge in practice. And I want to thank him for helping me getting there.

Transition artifact

You

Transition artifact

have this.

Transition artifact

Bill

Nancy Dishno

Meadow has a curiosity about nursing care delivery and asked me to be his nursing preceptor. We worked together twice as a preceptor and student team. He was on time for a 7 a.m. report He stood next to me listening to the night nurse talk to us with a confused expression on her face. He was not on service at the time, and he would be working with me during rounds when consulting services would come in to see our assigned patients. Maybe you can imagine the looks and questions we received. Is this a joke? Why is he doing this? Wouldn't it be great if we could all learn about each other's work and be precepted in this way? It would help us to better understand our own role on the team if we can see caregiving through the eyes of others. The first time we worked together, we were assigned a one kilo infant that was being ventilated with a high frequency oscillator. The numbers on the monitor showed the baby was very stable. Our first action of the day was to turn the baby over to check her out. When we did this, a storm of bad alarms began to come out of the monitor and the baby turned blue. Bill looked at me and said, this baby is sick.

Nancy Dishno

We began to work to improve the situation. The ventilator settings were increased, blood cultures in the CVC were drawn, and antibiotics were started. We got so much caregiving done in a short period of time. The process of medical care became timely, efficient, and individualized. This baby and her family were the recipients of the best that medical science has to offer, and it was exciting to be part of that. I think Bill's secret motive to work with me was to play with the many NICU mechanical gizmos. IV pumps, radiant warmers, monitors, and bedside blood testing machines are a few examples. One day, he got to press the button to send a tube to the lab.

Nancy Dishno

After that, I started back to the bedside, but I noticed he was still standing at the station, staring at the tube. I said, come on, Bill, we've got work to do. His response was, but it didn't go. If you're familiar with the use of the tube system, you know it gets heavy use and it's not very quick. Those of you familiar with our pre-2005 NICU know our old unit was quite crowded and intimate. You could easily hear other conversations. One busy day, while we nurses were scurrying around, a mother came into the room to visit her baby. A resident noticed her visiting and went over to talk to her. Soon after the resident left, the mother began to cry and then wail. the most heart wrenching sounds I've ever heard. It was uncomfortable listening to her. I didn't know how I could help her, so I paged Bill. He came into the room and introduced himself, sat down, and began to talk quietly to her. I couldn't hear what he said. While he was talking to her, she stopped crying, started to smile, and let out a laugh. When he left the room, she had a smile on her face. I couldn't believe the transformation I saw. I said to myself, I want to learn how to do that.

Nancy Dishno

Bill's service rounds have included joke telling, singing, sports facts, rock and roll trivia. This may have surprised some people. But I've noticed his humor has a calming effect, especially on the first year July residents.

Nancy Dishno

My first takeaway from this is that while the bedside care team is busy providing care for patients, we should also be taking care of each other. Good care comes out of good work relationships. My second takeaway is that humor and humility can change all our relationships and make them into more meaningful human connections. Thank you, Bill, for sharing your way of making meaningful human connections with the rest of us.

Dr. John Lantos

A lawyer was on the faculty of the law school here for many years, sadly has now moved to Harvard. You're just wrong, Cass. I love you. But he and Bill collaborated on some studies you've already heard about. And we're going to find out how you get to be a doctor who publishes in the Duke Law Journal.

Dr. Cass Sunstein

Great. So heard about Bill as a sports coach. Bill is a sensational athlete. He played number one on his college team in squash and played varsity tennis. I'd say there are three characteristics of Bill as an athlete that you need to know. First, he's cute. He is very, very dexterous with his hands and his eyes. The second that you need to know is that he's vicious. He can hit the shit out of a squash ball or a tennis ball. Unlike most squash players, he has a fierce topspin backhand and a fierce topspin forehand. That's very unusual. And his backhand cross-court in squash, I still have nightmares about. I'm screaming and Samantha has to say, what happened in your nightmare? Bill hit that cross-court again. But the third thing you have to know about Bill as an athlete is he actually cheats, I have to say.

Dr. Cass Sunstein

The way he cheats is if his opponent hits the ball out, he calls it in. He cheats. And the more we played tennis, the more I could hit it out and it would still be in. Three inches out, four inches out, in. As I played with Bill over the years in tennis, he would start kind of commenting on my game. First we were like, friendly competitors, and we became very, very close friends. And he would say, make observations about me as a tennis player. He said, a lot of people underrate you. You're very, very underrated. Now, that's an odd thing to say, because

Dr. Cass Sunstein

I think there's no one on the planet who thinks about my tennis game. I'm just not rated. He said, you're really underrated. But then it occurred to me there was logic in this statement, because the court had become so large after his cheating on my behalf that I actually was underrated.

Dr. Cass Sunstein

OK. Here's the site of a squash court, just so for orientation. That looks like where we played, not exactly where we played. That's exactly where we played. And you can see the white lines. If you expand them out a foot or so, that's what I got. That's Meadow on the left in the kind of orange. That's Bill. That's me on the right. That's in the late 1980s. That's us.

Dr. Cass Sunstein

I've got my arm around him having lost. And he's comforting me as usual. Here's an abstract from the Duke Law Journal. I should tell you the origins of this. First, we were really sports buddies. And he would talk about piglets. I didn't quite know what a piglet was. Is that a small pig? Piglet. And so I had, he was doing some science thing. And then it turned out he's like a great human being as well as a great athlete. And turns out he does research also that involves human beings as well as piglets. And I got interested in behavioral science and we talked about this. So the idea in our paper is that we really need to rely on evidence, not opinion. Experts, as noted, make predictable errors. They're actually not just random errors, which would be interesting, but they're systematically in the direction of optimism, which is to suggest that expert witnesses are systematically incorrect. and excessively optimistic. Now, that's a strong statement. Lawyers tend to be more equivocal with more mites and footnotes. That's Bill's statement. So we asked two groups of experts. When I say we, I mean Bill. Our paper asks, courtesy of the first author, Bill, ID doctors and ER doctors, how long until kids with meningitis get antibiotics. These are people, you know, probably on average a bit more likely to nail the answer than expert witnesses who are paid. And we asked, we got these answers. 56 minutes from ER doctors, 87 minutes from ID doctors. The actual record suggests the average time is 93 minutes. Published reports suggest 120 minutes. which suggests that experts were wrong by a very large margin. That has consequences for the legal system. OK, the upshot is whatever expert opinion means in this context, it's not accurate. Expert opinions were significantly shorter. And there's systematic bias toward the outcome perceived to be desired. OK, here's another abstract from a journal I've not published in often.

Dr. Cass Sunstein

But I think Samantha will be pleased to hear that I've published once there. The frequency of antinatal, and then there's this word that begins with C,

Dr. Cass Sunstein

use for mothers with threatened premature deliveries versus recollections. And the same story there is provided here, where expert opinions on use outside of a courtroom, which is to say the expert opinions are more likely to be distorted by motivation. There you see an extremely large disparity across four different time periods. Okay, so uh-oh is the implication. The use of antinatal Cs by obstetricians in the past 15 years shows a phenomenon widely recognized elsewhere, that is retrospective memories are often wrong, and when they're wrong, they're not randomly wrong. I should say what Bill's contributed here is something very large in a context in which behavioral science has moved. The largest kind of psychological finding, at least in areas in which I work in the last three decades, I think, has been Kahneman-Tversky's finding that human error is not randomly distributed, that there are systematic patterns that can be identified. That's new. Now, to find that with respect to how many words have N as the first or third letter on a page, it's kind of interesting about cognition. But to show it actually has implications for how doctors think and how doctors who are likely the expert witnesses think and how the legal system behaves, that's a really big deal to show not random error but systematic error. OK, so our proposal is that the standard of medical care should rely on data rather than recollections of experts about doctors' performances. Fallible memories of isolated experts are a crude second best, far inferior to the data that they approximate. I'm reading the full sentence here under Bill's tutelage. Widespread adoption of this view, beep. beep, beep, by professional physician organizations would dramatically increase the rationality of expert testimony in medical malpractice tort law. Now last I looked, there hasn't been widespread adoption of this view. And medical malpractice tort law hasn't gotten there. So the court system isn't there yet. But there's something actually quite larger that has gotten there, which I think is causally connected with what happened in the locker rooms in Chicago in the years where you saw the pictures, where there's a memorandum from the White House. And this is one of about five in which it is stated by the people in the White House that the president wanted an aggressive management agenda for a second term that delivers a smarter, more innovative, and more accountable government for citizens. And I'm just summarizing this quotation as a summary quote. by applying existing evidence about what works, generating new knowledge, and using experimentation innovation to test new approaches to program delivery. Now, this is part of a bunch of things which are now hardwired into the DNA of federal government agencies. This isn't about a Democratic or a Republican president. It's about the inclusion

Dr. Cass Sunstein

of evidence-based judgments in the day-to-day operations of the federal government. In some ways, the most stunning aspect, if we can call it Meadows' greatest victory, except I think that's 6-3, 6-4 time. You crushed me back in 1997. Aside from that is that for budgets, the budget proposals now have a large component of something like what you saw. in the Statistics Not Memories and Statistics Not Experts work. Here's something also from the White House, which in the fullness of time, I think will deliver very, very large results. And what this does is basically what Bill's work did on Statistics Not Memories, Statistics Not Experts for federal regulations, whether it involves regulations involving the environment, regulations involving healthcare, regulations involving transportation safety, regulations involving immigration, where there is a systematic review which has the title in it retrospective analysis occurring according to this 2011 memorandum with 120 days of May 18th, but much bigger and better. This is actually happening quietly within the federal government every six months.

Dr. Cass Sunstein

where there is evidence-based retrospective analysis of what's happened, not with reference to doctors' judgments, but with respect to everything that the federal government does. Now, thus far, the presentation has been consistent with the theme of the Meadow-Sunstein articles. That is, statistics, yes, memories, no. But I want to equivocate a little bit. It is true that data is king. It either is 6-4, 7-6, 8-6, or it ain't. That's true for medicine, law, and policy. There's a mantra now which combines the world of sports with the world of government. It's called Moneyball for Government. And the idea really is to make this systematic. And that is the theme of the articles. Still...

Dr. Cass Sunstein

I'm sticking with memories.

Dr. Cass Sunstein

On the right, it looks like a triumphant John McEnroe. My recollection is that is Bill Meadow. The guy with the really long hair looking discomfited at having lost, that's me. And here's the real deal. On the left, you see Someone with a big bright smile, unforgettable, smiling and comforting, a loser.

Dr. Cass Sunstein

Who's smiling because he gets to be with the best sports partner ever. Thanks.

Dr. Joanne Lagatta

to not replicate things that the other speakers have already gone through, so I guess that takes me through the title slide. So he also asked us to offer one or two Bill stories and comment on how they relate to what we're working on now. The problem with those instructions for me is that as a resident clinical fellow and research trainee under Bill, that doesn't narrow it down very much, everything I know about neonatology or research I learned here. So as anyone knows, oh, is this the clicker? Who? has rounded with Bill Meadow on 60 babies in under two hours. There is one way to get through rounds, which is with a one through 10 checklist. Before there was Atul Gawande, there was number one, nutrition, NPO, number two, fluids, TPN, number three, on event, can't fool you, and so on. So as a proud and grateful former fellow, I present my personal one through 10 list of Bill Meadow's influences on my career.

Dr. Joanne Lagatta

So the first is obvious here, breadth of teaching. I met Bill in 2005 when, as a second year resident, I had the great fortune of rotating on his service in the NICU. And I quickly learned why everyone begs to work with Dr. Meadow. His teaching skills are famous, enthusiastically covering everything from neonatal physiology, delivery room resuscitation, neurotransmitters, end of life conversations, the entire gamut. In an academic world where junior faculty members are coached that only a razor sharp focus gets you funding, it's Bill's energy and expertise on many topics that trains clinicians around the world and inspired me, like many others, to pursue neonatology as a career.

Dr. Joanne Lagatta

The second is a phrase that I will borrow that I've been thinking about more recently, which comes up on rounds only when you're on with Bill, which is paradigmatic neonatology. Can I do that because I'm a spelling bee champion? In the NICU, clinical management can feel dominated by a sea of numbers, lab values, ventilator settings, tiny drops of milk. Bill teaches us to think first about the natural course of a baby's condition. He wants us to understand in words, not in numbers, what we expect to happen. Now that I'm the attending receiving information overload on rounds, it's this reframing that helps me more than anything else. In research, Bill coaches us to both analyze data and think about what concepts those data represent. Although I did not love continually being told I don't believe in logistic regression during my fellowship, I am now able to collaborate across institutions because A, Bill introduced me to those collaborators in the first place, and B, he taught me to communicate what numbers mean.

Dr. Joanne Lagatta

The third is scholarly mentorship. Bill sets up his trainees for success by teaching us to write, to speak in professional settings, and to receive critical feedback. Lots of critical feedback. His lab group knows to save every version of a poster, paper, or presentation because we will go around in circles many times before settling on a final version. I now realize how much that process taught me about writing, and I appreciate the incredible gifts of time and experience embodied in those unending track changes. As Bill himself typed in red capital letters across the top of a grant proposal I sent him, remember, when the coach stops yelling, it means he doesn't care.

Dr. Joanne Lagatta

Number four is career framing. Trainees and junior faculty in academics face the hurdle of trying to articulate how that one fellowship project we did now sets us up for a program of research. Bill always knows what the next paper is about, and the one after that. There is a reason why so many of us training at the University of Chicago end up working in neonatal ethics. He lays out the path so clearly and enthusiastically, it's hard not to join in. I can only remember one project that Bill suggested to the fellows, which did not conclude with, and then this will make your career, because, followed by an entire life plan. In full disclosure, the project cell actually began with, and then this will make your career, ended with, okay guys, I'm really kidding, it won't make your career. I just need two hours of somebody to pull some data. Can you do that for me? And ended up being a fantastic international comparison of end of life care with many of the speakers in this room and people who are now my current colleagues since I speak neither French nor Dutch. But I do speak Wisconsin, this turned out pretty well for me. So I guess it did make my career.

Dr. Joanne Lagatta

Number five is collaboration over competition. In an academic environment, junior folks are asked to develop their personal niche and set themselves apart. Bill is adamant that the world is small, that the need for more research is large, that there is always room in the sandbox, and that collaboration is paramount. He models this behavior by the guidance he offers to people around the world. When I was first interviewing for a faculty position at the Medical College of Wisconsin, the department chair, who's, he's not here, right? A famous and slightly intimidating neonatologist asked me, how

Nancy Dishno

are you going to get out from under Bill?

Dr. Joanne Lagatta

And now that I have the job, I can answer that question honestly, which is that I don't plan to try. Although some of us may move to other institutions, we never leave Bill Meadows' lab because you don't find such a productive and effective team anywhere else. So the next points are the central academic concepts I hope to carry with me from Bill's research, embedded in the introductory statement he makes in talks around the world. If suddenly you were forced to think hard about extremely premature infants, what would you want to know? If you were a doctor, a health policy maker, or a parent?

Dr. Joanne Lagatta

So that brings me to point number six, which is that outcome definitions matter. This sounds obvious in an ethics audience. Different people care about different health outcomes. But it's not so obvious in clinical research. Major neonatal networks commonly report composite outcomes of either death or some major morbidity, for example, developmental delay or chronic lung disease. The rationale here is that infants who die before discharge don't survive to have some of the later complications of prematurity. Bill argues that from a parent's perspective, death or disability is not a relevant outcome. In fact, for parents debating whether or not they want physicians to attempt resuscitation of an extremely preterm infant, death is not the worst outcome if it means they gave their baby a chance.

Dr. Joanne Lagatta

Point number seven is that although outcome definitions matter, complex statistics do not. This is a... This is a bittersweet lesson for me after completing a master's degree on this campus, but the best thing that happened to my academic training was learning to analyze large data sets here while working with Bill studying the ability of healthcare providers to predict outcomes for individual patients. We get pushback at national meetings for putting clinical intuitions in the same category as a more, quote, objective test like imaging or a lab value. But it seems to a clinician reasonable to think that a doctor in the NICU is as likely to act on their own intuition as on the results of a blood count. Bill meets resistance at Thursday conferences when he says repeatedly the only thing that matters is positive predictive value. But for a patient or a parent, it's true. And once we start comparing the ability of a clinician's intuition versus another test to predict an outcome, suddenly it doesn't make a lot of sense to report that somebody's clinical intuition is 1.2 times plus or minus something more likely to predict an adverse outcome. All you want to know is what's going to happen. And so from that, I conclude that research results should be presented according to who's asking the question.

Dr. Joanne Lagatta

Point eight was the hardest one for me to come up with how to summarize this, and it's that outcome prediction ability varies over time. Having done my residency and my fellowship here, I always took the clinician intuition study for granted. Many people in this room know this study every day on every ventilated patient. Friendly post-bac students offer candy in exchange for clinicians' predictions of whether or not the infant will survive to discharge or die in the NICU. Intuitions are only collected on that day if the infant is on a ventilator because those are the infants for whom a decision about withdrawing intervention is ethically relevant. That all felt straightforward to me until I was presenting a poster and someone asked me whether or not those clinical intuitions predicted developmental delay because they were a proxy for other things that were known by the clinicians. So in trying to answer that question, I tried to figure out how one might present clinical data like intuitions in the order in which it was known to the clinician. I learned a few things during that process. First, there is a reason why few people other than Bill Meadow study things like changes in predictive ability over time. That's really hard. Second, some pieces of the quote gold standard predictive information like gestational age actually become unimportant over time. And unless you're Bill Meadow, that's very hard to sell to an audience. Third, more broadly, it's possible and important for any research question to think not just about what the question is, but when a decision might be relevant, and tailor your study accordingly.

Dr. Joanne Lagatta

Number nine, if an outcome is uncertain, who decides what to do next? So this is embedded throughout Bill's work. Anyone who's heard him speak knows this line, hi ma'am, I'm Dr. Meadow, your baby is very sick and I think is likely to die. We here at the University of Chicago study these things and you should know that I'm wrong half the time. In the context of predicting death in the NICU or in predicting a spectrum of developmental delay, it makes sense to most audiences that parents should then decide whether to continue NICU intervention. But this speaks to the clarity of Bill's message. There are many questions in neonatology where our outcome predictions are poor and our clinical decisions have consequences for families, yet it's rare to conclude that parents have a voice in that decision making.

Dr. Joanne Lagatta

So as I carry Bill's lessons forward, I've been learning how these teaching points might be applied to other clinical research questions. As I finished fellowship and was looking for a project, Bill put me in contact with the folks at the Pediatrics Medical Group, a large private neonatology group with detailed, de-identified electronic medical record data on 20% of all NICU patients in the US. In an example of networking at its best, Bill just happened to know their head of research from having sung together in a men's choir at Amherst.

Dr. Joanne Lagatta

So we started looking at use of home oxygen among preterm infants with the rationale that parents don't care that much about a diagnosis of chronic lung disease, but they do care about whether or not they need to take an oxygen tank home with them at discharge. We ended up finding huge variation in use of home oxygen adjusted for illness severity, and that NICU's use of home oxygen for infants with BPD was tightly correlated with length of stay. I have one data slide here that's actually not important. I will probably not just read the slide. But the point here is that on the y-axis is the gestational age at discharge. On the x-axis is each NICU's rate of home oxygen use for kids with chronic lung disease. And you can see that the more NICU is likely to use home oxygen, the earlier they discharge the patient with a variation of nearly a month.

Dr. Joanne Lagatta

So that paper has now served as some background for some prospective work that we have gotten some pilot funding for. And we're interviewing parents about how they perceive the trade-off between NICU length of stay and shouldering the responsibility for medical care at home. More fitting, we're now conducting that study both in Milwaukee and here at the University of Chicago with Bree and Marin as collaborators, which I'm very excited about. So there are so many more Meadow rules that I should list. For example, Beanie told me recently that I have violated the Meadow rule of childbearing. I am not actually sure what that rule is, but I am sure that it recommends not having three children, two and under. Nonetheless, at least two of them will graduate at the same time, God willing, so that's not bad.

Dr. Joanne Lagatta

Nonetheless, I feel prepared to maintain my academic progress, primarily because we have a spectacular nanny, but also because of the clinical and research skills, professional development, love for what I do, and strong network that I owe to being trained by Bill Meadow. So I will close with point 10, which is what to do when there are a lot of points, and that is to keep your priorities in order. Bill is known for being high energy about just about everything, but you can always tell which of his teaching points are the most important when he slows down to say them. The ones I know are the following. Whatever you do, promise me you won't be boring. Whatever you do, just keep writing. And whatever you do, get the tube in.

Dr. Joanne Lagatta

Although I can't make any promises on the first one, thanks to Bill's mentorship of my clinical and academic career, I can make good on the other two. Thank you so much.

Dr. John Lantos

Coming down the home stretch here, thanks to all the speakers. Wonderful presentations.

Dr. John Lantos

I had a whole talk, but most of it's been covered. So I'm just going to sort of give a little gloss on what other people have said. Bill and I have been Friends and colleagues, for 30 years now, we've coached soccer together, gone on dozens of trips to SPR, celebrated Passover together at the legendary Meadow Family Seders, which never numbered under 40 people, traveled the world together. I couldn't have raised children without Bill. My daughter, Emma, who's here, would never have gotten into medical school without the Meadow chemistry tutoring. We've written 38 papers and one book together. Our style of collaboration over the years has been simple and straightforward. Bill focused on the data. I was more into ethical theory, or as he liked to put it, I'll do the science, you do the bullshit.

Dr. John Lantos

It worked well.

Dr. John Lantos

I mean, as you've heard, Bill is a bit of an iconoclast. I mean, the story of the trip to McGill in Canada is now the stuff of legend. People didn't talk much about what he actually addressed when he was there. I mean, he challenged the prevailing practices. He defended slow codes, which he was well practiced at doing after sparring with Laney. I think he even suggested that all 23-weekers should be resuscitated, which was not at that point, the prevailing practice north of the border. And as you heard, he was banned from McGill for life as a result of these radical opinions. But that wasn't the end of it, actually. After he left McGill, the director of the bioethics center there, a lawyer named Kathleen Glass, was so horrified at what the students had been exposed to that she called an emergency meeting of the first year class. The ones who had attended Bill's lectures to explain why Bill's ideas were not just completely wrong but dangerous. In fact, Bill was treated in essence like a bioethical toxic waste dump.

Dr. John Lantos

Students who were exposed had to be decontaminated. I've seen Bill shock audiences at scientific meetings as well. One year, he and I were on a panel at the PAS, the Pediatric Academic Society's meeting about the ethics and the efficacy of treating babies at the borderline of viability. And it was put together by the NICHD and had a lot of people who believed in linear regression and that sort of crap.

Dr. John Lantos

The first speaker was Rosemary Higgins, the head of the NICHD Neonatal Research Network, and then John Tyson, who had done phenomenal work developing the neonatal calculator that we saw earlier. And then Bill came up, and he went up on the podium with his crocodile Dundee hat and started his presentation. but by singing a rousing rendition of Smokey Robinson's hit, Baby, Baby, Don't Cry.

Dr. John Lantos

Which starts, nothing so blue as a heart in pain, nothing so sad as a tear in vain.

Dr. John Lantos

Afterwards, one of the other panelists, I think it was John Tyson, took me aside and said, you've got to tell him he can't do that.

Dr. John Lantos

This is a serious topic.

Dr. John Lantos

And I said, well, yeah, it is a serious topic, but music is serious too. And sometimes the best way to address serious topics is to get to the emotional heart of them. There is nothing so blue as a heart in pain. And sometimes all we can do is be there with people whose hearts are suffering and offering them a caring connection so that their tears will not be in vain. One of Bill's mantras was always don't abandon your patients. Doctors can't always make the experiences of parents in the NICU less sad, but by being with their and not abandoning them, doctors like Bill can reassure them that As the chorus to that song goes, love is standing by.

Dr. John Lantos

As you've heard, Bill Stiles as a soccer coach was as controversial as his bioethical ideas. His record in the Mayor's Cup soccer tournament is comparable to Coach K's at Duke. Bill always played to win, as Dan Brodny said. But what Dan didn't say was when Bill left the American, the AYSO soccer league, he did not leave voluntarily.

Dr. John Lantos

In fact, I think it's the case that he is the only AYSO soccer coach who has been banned for life.

Dr. John Lantos

And people have talked a lot about his compassion in the NICU. Not on the soccer field. I didn't have the experience of working with him when he coached the boys. But my daughter Emma and Beanie Meadow were on the same team. And coaching girls is a different beast than coaching boys. Girls think that if you cry, people will pick you up and hug you. It's the way that Bill's style was. Stop crying or get off the field. You're in the way. As Dan Rudney said, the Hyde Park Red Dog parents spent many Saturday mornings together in really bad weather in really bleak suburbs.

Dr. John Lantos

The Red Dogs were one of the few teams to focus on a primarily defensive strategy, sort of like the Italian national team. Our strategy was sort of like, and this is gonna be an extended metaphor, so bear with me. It was sort of like that used by Muhammad Ali against George Foreman in the Rumble in the Jungle, the championship fight in Kinshasa Zaire in 1974. That fight, as I'm sure you all recall, was one in which Ali was the underdog. The 25-year-old George Foreman was heavily favored to pummel and destroy the aging Muhammad Ali. Ali had a strategy, though. He let Foreman pummel him for the first six rounds mercilessly. And in each round, Ali would get him in a clinch by the ropes, and he'd whisper in his ear, is that all you got, George? I thought you could hit hard, George. Is that all you got? And Foreman took the bait, trying to hit harder and harder for six rounds. And Ali just took the blows. And in the seventh round, he came out swinging. Foreman was exhausted. and Ali decked him. Why am I telling you this? Bill's Hyde Park Red Dogs used a similar rope-a-dope strategy.

Dr. John Lantos

We would pull back on defense with Beanie Meadow at the center and let the other teams take numerous wild shots, and we would hope that just once, Ali Brodny would break away for a goal. And when she did, Bill's coaching genius really became apparent. In club soccer, unlike in more organized leagues, you may know there are no ball boys. So if you kick a ball out of bounds, someone has to run after it and bring it back. So if we got up by one goal, Bill instructed the girls to kick the ball as far as they could. out of bounds every chance they got, and then they would rest, fall back, reset while the other team fetched the ball. It was a very effective strategy, but of course raises a serious ethical

Dr. John Lantos

question. Was it good sportsmanship? Was it fair? Well, as we say in ethics, it was a bit of a gray zone. So we've done a lot of work together in gray zones of one sort or another. Such work is not for the faint of heart. There's a lot of heartache, but thanks to Bill's wit, creativity, and moral courage, there has also been a lot of joy. Many grateful parents and students and a community here in Hyde Park and all around the world that recognizes Bill as a devoted teacher, a selfless colleague, a brilliant mentor, and a true friend. These have been tough weeks, or tough months, as you know, for Bill, so I'd like to just end with a Jewish prayer for healing. Some of you may know this prayer. May the source of strength who blessed the ones before us bless those in need of healing with the renewal of body,

Dr. John Lantos

the renewal of spirit, and let us say amen. Thank you all for coming to honor Bill and celebrate

Transition artifact

together.