Dr. Ronnie Guillet on Neonatology

Dr. Ronnie Guillet, M.D., Ph.D., is a neonatologist at Strong Memorial Hospital and Highland Hospital. She also teaches and researches neonatal brain development and injury at the University of Rochester Medical Center School of Medicine and Dentistry in Rochester, NY. Dr. Guillet earned her Bachelor’s degree in biology at SUNY at Albany, her Ph.D. in biophysics at University of Rochester and  her M.D. at University of Rochester School of Medicine and Dentistry. Dr. Guillet did her residency in Pediatrics at University of California, San Francisco Medical Center and her fellowship in Neonatology at Children’s Hospital of Philadelphia.

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JYI: Could you please tell me a little bit about your educational background?

Dr. Guillet: I did undergraduate at SUNY Albany, and then I started in graduate school here at the University of Rochester, I was in the Radiation Biology and Biophysics department. I started working on the development of the adrenal axis in rats in the lab of a veterinarian who was interested in microwave hazard research. He’d been doing X-ray hazard research and was part of the Manhattan Project and had transitioned into looking at microwaves and whether they were bad for you or not. I was interested in developing organisms so we were looking to see whether microwaves and baby rats, whether there was any effect on them, and the organ system that Dr. Michaelson was interested in was endocrine. We looked at the adrenal gland and what controls the adrenal gland from the brain. In the process of all of that I was reading a lot about children endocrine problems and asked Dr. Forbes, who was on my PhD committee if I could go to pediatric endocrine clinic with him. I started doing that and then one of the fellows I was working with said: “You should go to medical school!” And I told him all the reasons I couldn’t possibly be a doctor because I didn’t know everything, but doctors knew everything and they had to have all the answers and I knew that that was going to be a problem for me. And then a friend of mine who was a graduate student said, “Oh my roommate is in an MD-PhD program and she thinks you should apply.”

So I talked to a number of people, and ended up applying to medical school during my third year of my PhD. And during that year I was able to take some courses that both graduate students and medical students could sign up for. I finished three years of graduate work, during which time I had basically finished most of my thesis, and then during the summer and my first year of medical school I was able to finish writing my thesis, defended between my first and second year and then finished medical school in four years with my class. It was about a seven-year period. I was never pre-med, I never had any thoughts of going to medical school and I’m glad I did. I hated the first year of medical school, because I’d been pretty successful in the lab, I was self-motivated and all, and I hated being told what to do and how to do it and sit here and learn this. By the time we got to physiology and started thinking about things instead of memorizing things, I decided that I made the right decision.

JYI: So you didn’t follow the traditional path of the MD-PhD program…

Dr. Guillet: No. For most PhD students there is a variable length of time that it takes people to finish their PhD. Anywhere from four years to sometimes seven to eight years and there’s usually only one or two people in a department in a given year, and so it’s not like in medical school where there’s a class going through. It’s more flexible and more variable, and it depends on how well your research goes. It’s unusual to start and finish with the same medical school class if you’re in the MD-PhD because generally they’ll do the first two years in medical school, then do their PhD work, and either finish it or pretty much finish it, and then finish up medical school. So they get out of sync with their original class.

JYI: I read on the website that you also got a Master’s Degree?

Dr. Guillet: When you propose your thesis and defend your proposal, you basically get your Master’s. And then you do your PhD and then defend your PhD. It’s often in many PhD programs a step along the way; it’s rarely the end of the program, but I guess people who find that PhD is not really for them could come away with a degree and not just have wasted two or three years.

JYI: That’s helpful. And where did you do your residency?

Dr. Guillet: I did pediatrics in San Francisco, and neonatology in Philadelphia.

JYI: How do you choose where to do residency, or do you just apply and get chosen? How does residency work?

Dr. Guillet: In [the] third year of medical school you get the opportunity to do most of the major areas of medicine. You’ll do rotations in internal medicine, pediatrics, surgery, OB/GYN, you’ll probably do an emergency department rotation, some of the subspecialties, you might do radiology… And you decide what seems to suit you, your personality, what you’re most excited about. And between the summer of your fourth [and fifth year]  you start making your application to summer residency programs. You get invited to interviews, which are usually from November through January. And then there’s this big computer in the sky that matches you with the residency program. Some people know when they start, which general area they want to go into, some people have no idea, some people think they know and then third year they come across something that really excites them and they change. So you choose your residency, and during your residency, again, you might have had some preconceived notion that you wanted to be a cardiologist, or you wanted to be a high risk OB, or you want to be neonatology, but you get exposed to lots of different subspecialty areas during your general residency training. And then the same process: you go around interview for fellowships, which are more specialized training.

JYI: So you get to try everything.

Dr. Guillet: You do get to try most everything. Residencies are generally three to five years, depending on which specialty, which area you want to go to. Pediatrics is three years, OB/GYN is four years, surgery is five years… And then fellowships are generally three more years after that.

JYI: Did you merge your research focus with what you do in the clinic?

Dr. Guillet: I’ve always been interested in brain development and from the time I began working on my PhD when I was looking at the hypothalamus, pituitary and adrenal axis, so including the brain, to what I did in my fellowship to what I’m doing now, a lot of it has to do with brain injury, brain development, neonatal seizures, so, yeah, it all ties together.

JYI: How do you think it helps to have both a medical and a research background?

Dr. Guillet: With only a PhD it’s more challenging to get access to patients, you have to really collaborate with a physician. If you’re a physician you can do clinical research…At least in the past there wasn’t quite the same critical thinking and training that you get as a PhD student, although now with the emphasis on the evidence-based medicine, you do get a little bit more of the scientific method in medical school. But I think you learn to think a little bit differently when you’re trying to come up with a research question for your thesis. So I could, and there are a lot of my colleagues who do basic science or clinical research with only an MD, so that’s certainly feasible.

JYI: What do you do right now?

Dr. Guillet: I do lots of things, not all at the same time. As far as taking care of patients, about sixteen weeks out of the year, I’m working in the NICU [Neonatal Intensive Care Unit] or up in the special care nursery at the Rochester General [Hospital], so I’m doing direct patient care. I’m the chief of pediatrics over at Highland Hospital, so probably 25% of my time is administration, so all the protocols over there, overseeing the providers, doing all of that. Probably, 25-40% it depends on the particular year about that amount of my time is doing clinical research. I do teaching in and among all of that, sometimes I’ll be a facilitator for a medical school course, I teach medical students, residents, [and] fellows while we’re taking care of patients. I’m involved in a number of different clinical research projects at this point. I’ve branched out a little bit from the brain, I’ve recently become involved with a group of pediatric nephrologists, they’re interested in kidney disease in preemies. I was the neonatologist who knew kind of the care protocols for preemies and they know a lot more about the kidney than I do, so we’ve been starting to collaborate, and it’s been about fifteen or sixteen hospitals around the country, all trying to work together. So I do a lot of different things…

JYI: Many different jobs at once!

Dr. Guillet: Yes, started a curriculum for junior faculty to help them get some of the skills that they need to do a good job in their career and advance quickly. The longer I’ve been around, the more things I’ve had the opportunity to get involved in.

JYI: Is this something you like about your career?

Dr. Guillet: Yes, and every time I’m on servicing a patient, almost every time I’m on service, I see something I’ve never seen before. And that’s the nature of neonatology. My husband’s a retinal specialist, and it’s been years since he’s seen anything new. So, that’s why what I’m doing is, you know, keeps me interested and excited and learning new things.

JYI: Would you describe your day at work? While as a researcher, or clinician, or I guess that would be two different days.

Dr. Guillet: Well, today for example I was here at 7:30. I’m down at the NICU but I’m on the Green Team, and the Green Team is our convalescent babies, so not the ones that are acutely ill but the ones who are feeding and growing, they may have been born three or four months early and now they’re learning to eat, they may need a little bit of oxygen but not much, they’re getting ready to go home. So I spent all of the morning seeing those patients, talking to their families, doing my paperwork. This afternoon I was able to do some of my other administrative things. I was working on trying to work on this kidney project and some of the data forms. I had to go down to the nursery because we had pulmonary rounds. That’s kind of like the typical clinical day. If I was on the acute care team, I’d be here by 7 and I’d be lucky if I got out by 7. When I’m on the chronic team I should be able to get out at my usual time, which is 5:30-6-6:30, something like that.

JYI: Would you say that the research that you do is translational research?

Dr. Guillet: I think you can define translational research in lots of different ways. Yes, I think what I do is translational; it’s bringing some of the things people have found doing their research to the patient. I was interested in neonatal seizures and bringing what I learnt in research to the various protocols we use to take care of the babies. Sometimes when babies are born, term babies, and they have a very difficult delivery and don’t get enough oxygen at the time of birth, they can end up having some brain damage. And we were involved in two of the big clinical trials looking at cooling these babies. So normal body temperature is 37ºC. If we cool them to about 33.5ºC to 34.5ºC for three days, their outcomes are much better. So we participated in two big studies, and now that’s what we do for all of our babies who’ve been asphyxiated at birth. So in that sense, yes, I’ve done some of the research, and now we do it for our patients.

JYI: Would you say that most of your ideas for research come from medical observations, from medical problems that you see and that you want to solve, and you turn to science to find a solution?

Dr. Guillet: Yes, and some of them can be done with straight patient studies. Most of them, it takes several years to get to that point, because especially if you’re going to do an intervention – you’re going to treat it with a new drug, you’re going to use a new device – you always have to start with animal studies in order to make sure it’s safe in animals, that things are going the way you predict that they would go before you would even bring it to an adult, no less a baby.

JYI: Will the patients know that they are part of an experiment?

Dr. Guillet: Absolutely, the parents will have to sign consent. We spend a lot of time talking to the families. For example one of the studies that we’re doing right now, we’re part of the NICHD, so the National Institute of Health and Human Development, the neonatal research network, so it’s 18 centers across the country. And one of the things that we don’t know is how low a baby’s hematocrit can get, so how anemic they can get safely. So when should we transfuse a little preemie. You could argue that you could let the hematocrit get very low, because you don’t want to increase the risk of giving them transfusions, because it’s volume, it’s somebody else’s blood.

On the other hand, the reason you give a transfusion is to have the red blood cells to carry oxygen to the tissues. You think something straightforward like that, people would know when someone should be transfused, but we don’t, especially for preemies, especially for the preemies that weigh less than two pounds at birth.  The study that we’re participating in, we talk to families and say we’ve got a study where your baby would be randomly assigned to be transfused either when their crit was at a higher level or a lower level, and then we’re going to collect a lot of information for two years, and see how they do. We spend a lot of time talking to the families, we have about a six-page consent form that we go through with them. We make sure that they understand, answer all their questions, and then they either consent or don’t consent. And probably about a third to a half of the people that we approach agree to let their babies be in one study or another.

JYI: I’d imagine it would be difficult to find many people who would agree to participate in a clinical experiment…

Dr. Guillet: There’s a substance calls surfactant. Surfactant is a substance that coats the air sacs in your lungs. And you ordinarily don’t start making it until you’re at least 28 to 30 weeks gestation. A baby born at 24-25-26 weeks usually has not started making surfactant, and they don’t for the first few days. If you don’t have surfactant coating your airways, the small air sacs will collapse in between each breath. The surfactant, which is a surface active agent – that’s where the name came from, keeps the airways open a little bit between breaths, so that the work of breathing is less. The baby doesn’t have to reopen their lungs from collapsed every time they breathe. Surfactant was developed here in Rochester back in the 70s and 80s, and it was because families were willing to let us put a tube down their babies’ trachea, their windpipe, and give the surfactant right into their lungs, and now that’s the treatment around the world for premature babies’ lungs. Without people who are willing to consent to things like that we wouldn’t be where we are today. And the same thing with that cooling for babies who are asphyxiated; before the cooling study there was really nothing we could do but support the baby and make sure they had enough oxygen and their blood sugars were okay, but we really couldn’t treat them, we could just stabilize them. When you explain that to families, you know, it is a stressful time, but a lot of families are very generous with their own time. It’s actually been shown that being in a study, you end up better off, even if you’re assigned to the placebo group. Because people think that just paying more attention to all of the little details, because they all have to be recorded for studies. A lot of reasons for people to participate.

JYI: What kind of students do you think would be suitable for the MD-PhD career and what advice would you give to the students who aspire to become MD-PhDs?

Dr. Guillet: It takes a minimum of seven to eight years for the schooling, and when you’re 20-21, that sounds like a long time. It’s not really that long. Like I said, you can as an MD do research, so you can go that route, but if you want more rigorous training on really scientific method, that would be the way to go. You have to be somebody who is curious and thinks of questions and realizes that nobody’s answered that question, and you want to do that. So you have to be curious, and not just want to go out there and care for patients, you know, be a primary care physician. Some people just want to go out there and be in rural medicine, and be a family doc and take care of people and they’re good at that and support them, and that’s fine, they will do evidence-based medicine, read all the literature and figure out what is the right thing for their patient, but they’re not the ones necessarily who are developing new information or new ways of doing stuff in a rigorous way.

JYI: It seems to me that many PhDs spend a large amount of their time looking for funding to do research, is it the same for medical researchers?

Dr. Guillet: If you want to do research, there’s a certain amount you can do on the cheap. Your time is valuable, but if you’re salaried, or if you’re doing it on your own time, you could do that without government funding or foundation funding. But if you want to work in a lab, it costs money. If you want to do a big clinical project, you need research coordinators and research nurses, and you have to pay their salary. And the NIH goes through periods where funding is either hard or harder to get. So, yeah, you could do retrospective data analysis with big databases and develop hypotheses, but to move clinical research or to do basic science research, yes, you have to get funding. It used to be much easier, but money’s gotten very tight.

JYI: What do you think your future will be like, do you have personal plans in terms of career?

Dr. Guillet: Yeah, to retire and have fun. And stay involved and teach, and we’re thinking of retiring in the next few years down to Georgia, and they just opened a small hospital there, and I could see volunteering to teach residents and medical students and stay involved in some of the clinical research projects that I’m involved in now – things I could do from a distance.

JYI: So you said that you think that the medical training has changed a bit, that it became more rigorous, that the scientific method has become implemented more…?

Dr. Guillet: People are really focused on evidence-based medicine. So not just “I watch somebody do this and it seems to work, therefore, I’m going to do the same thing.” Or “I try this, it worked, I’m going to do this for the next patient.” People became much more rigorous, and looked at the literature, and if it was 200 patients, 100 in each treatment group and really looked at all the statistical outcomes of the treatment. So really look in the journals and say “It’s not just what I feel is right, but it’s what someone has more rigorously shown is right.”

JYI: And how do you think science and medicine will continue to change?

Dr. Guillet: Genetics is probably going to change medicine tremendously. It already has in the last 10 years, and I think in the next 10-20 years it is going to be totally different, because when I was in college, Watson and Crick had just described the double helix. And now you can do genetic analysis, and they can identify whole exomes, so exactly what genes are there and which are different and do micro overlays and really define things, they can tailor chemotherapy exactly for the tumor…what receptors are coded for and not coded for. It’s incredible, what they can do. And I think, that’s probably going to make the most difference. Everybody will know their own genetic makeup, and whether you wanted to know it or not … you know genes aren’t everything, environment has something to do with it and you can modify many things. But I think it’s going to make a tremendous difference in personalizing medicine.

JYI: Thank you very much, Dr. Guillet, for your time and for the informative conversation!

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