COVID-19 is the most far-reaching public health emergency in generations, and its long-reaching effects have overwhelmed and overtaxed the health care community. Guest Dr Reena Patel, an emergency medicine physician, shares her personal story about how the last two years treating patients amid staffing shortages and systemic issues amplified by the pandemic led to feelings of stress, frustration, and ultimately burnout.
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Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward program is open access and free to all at stepsforward.org.
Jill Jin, MD, MPH: Hi everyone. And welcome. I'm Dr Jill Jin, your host for today. As you may know, typically our guests that we interview here are health care leaders and innovators in the field of physician burnout and well-being. Those who are leading the efforts in practice transformation across the country today. However, I want to take a pause and remind everyone who we're doing all this work for. The full-time practicing physicians whose sole job is to see patients who love their patients, who generally don't have protected or compensated leadership time or other roles or responsibilities outside of patient care. These are the physicians who are at highest risk for burnout, and whose voices are often. Ironically, the ones lost in all our grander efforts to combat burnout. And so, I'm taking the opportunity today to speak with a fellow physician and friend and invite her to share her story with us. Not because it's super unique or inspiring or sad, but rather because it is so common to hopefully remind us of how valuable these stories are to listen to and share amongst each other. Hi Reena.
Reena Patel, MD: Hi Jill.
Dr Jin: Thank you so much for chatting with me today. Can you start by telling us your name, your specialty, and your current practice setting?
Dr Patel: So, my name's Reena Patel, I'm a emergency medicine physician, and I currently work in a small community hospital in an urban setting, I would say. And I've been there for eight years now.
Dr Jin: And are you burnt out?
Dr Patel: I think so. Yeah. you know, it's hard to say, but I've hit the, the 10-year mark and that just correlated with 2020.
Dr Jin: 10 years in practice?
Dr Patel: Yeah. 10 years out of residency, and it kind of correlated with the pandemic starting, so now it's year 12.
Dr Jin: Got you, yeah. So how do you know you're burnt out? Or what kinds of signs do you see in yourself that makes you think you are burned out?
Dr Patel: Because we look—I've been getting to rethink why I went into medicine and, you know, I wake up some days wishing that I had never gone to med school. Wishing I had chose another career dreaming that I'd have a nice office with a window view of the lake, eight to five hours. Sometimes I think about maybe it's ER, and maybe I should have picked a different specialty when it came down to what residency I wanted to do.
Dr Jin: And did those thoughts just start in 2020 or before that?
Dr Patel: They started about mid to late 2021, actually.
Dr Jin: Oh, okay.
Dr Patel: Okay. I found myself calling a, a job recruiter looking for a job in Montana. I actually, I called and the job was actually on the border of Wyoming and Montana, and I was pretty serious about it.
Dr Jin: Another ER job?
Dr Patel: It would be another ER job, but the setting would be so different.
Dr Jin: Okay. So, tell me more about, so 2020, you know, was the start of the pandemic and you said that this kind of this burnout crisis didn't start until 2021. So, kind of tell me about how things shifted and evolved in that year.
Dr Patel: So, 2020 there was a lot of fear, but we didn't feel alone. We were all in the same boat in our ER community together, figuring things out and our priority in 2020 was just to stay alive. You know, so, and we did whatever methods we could. There's a Facebook message group that's EM docs, and we would share ideas through this and it kind of brought our community together. So, 2020 I feel like even with my family life, my work life, it felt whole, we were all together. It wasn't until 2021 that you know, you know, it's a year later, we're still in this mess and there's no clear sign of things getting better, and just things getting worse—2021 most ERs began cutting hours and taking away cutting expenses. So, they cut hours, they cut expenses.
However, the acuity of the patients, which is more sick patients we were experiencing, and also the volumes were going up. So, most of the ERs, either if it was a management company or a hospital employee, you know, everyone was taking cost-cutting measures just to make up for 2020 loss when volumes were down. What we witnessed in 2020 and 2021 are waves. So, when we would have a COVID surge, the volumes would go up, but it was never what we were pre-pandemic. But the acuity was high. And in between there would be, we'd be in a little lull where our patient population, I mean our patient per day were still on the lower end. It wasn't until end of 2021 or mid 2021 when volume started to pick up almost back to what they used to be pre-pandemic. We started noticing our hours were getting cut, which indirectly means our pay is getting cut, but we're still facing the same danger and we're actually seeing more sick patients. So, we're kind of working harder.
Dr Jin: Right. So, you're saying that they were trying to compensate for the lulls when no one wanted to go to the ER, because of COVID by trying to compensate for that lost revenue, they were taking away benefits for you.
Dr Patel: It was benefits like CME was taken away, most of us had scribes, the scribes got taken away, so we were doing our own charting. But the most important was the actual pay. If I go into work for a 10-hour shift and my shift gets cut to a nine-hour shift consistently, we lose pay because most ER physicians are not salary, we are hourly. And that one hour, you know, turns easily into 10 hours a month. And you know, if you do the math, you can easily be taking a 25 to $40 000 pay cut a year.
Dr Jin: Interesting. But at the same time, you were still seeing the same volumes sicker patients.
Dr Patel: Yeah. We were seeing higher acuity, more sick patients doing more procedures, still feeling the toll on our bodies at end of 2020, I was still feeling pretty good. You know, the vaccine, we were all waiting for the vaccine. You know, we didn't have a huge nursing shortage. We were still feeling good because in 2020, nobody made any pay cuts. We were still getting paid. We were, you know, everything was still the same except the face of danger. It wasn't until 2021 when things started really changing for the ER community.
Dr Jin: Yeah. You know, you were talking about the vaccine being, you know, very hopeful at the end of that year and then kind of, as it kind of peaked and people didn't want to get vaccinated anymore, how that really, you know, shifted your perspective on things. Can you elaborate on that a little bit more?
Dr Patel: Yeah. So mid-2021 when I started feeling the burnout, I have to say it was, you know, it was because of people not getting vaccinated for COVID. There were two populations, you know, the population that we take care of, our patient population. It was only 40% of the people at most. I think it was actually even lower than that in our community that got vaccinated. And when the second wave comes or the second or third wave comes around and young people with the delta, they come in, they can't breathe, you know. They're putting on, we're now using BiPAP again, and they want medication. They want, you know, they're asking about antibiotics, all these other treatments, and in our minds, it's like you didn't get the treatment. You didn't, not that it's a treatment, but a prevention you, we're all shouting in our minds.
Like, we can't say it, but we shout in our minds, you should have got the vaccine. You know, everybody wants like a miracle to happen. And there is no miracle, it's too late. You know, and there were a lot of young people who just didn't think it was going to be them, and they come in, and they're still there. They're what we call happy hypoxic patients where they're not distressed, but their oxygen stats are less than 50%. And they still are not phased by, they're still, you know, on BIPAP, texting, you know, and they still don't understand how sick they are, and the chances are, they probably won't make it out of the hospital. Yeah. It's just a lot. It's a lot of disappointment. You know, we stepped up in 2020 when COVID first came out. None of us, ER, physicians, respiratory therapy, nursing, ancillary staff, all of us showed up for work when we had to. We knew that our lives, our family's lives were in jeopardy, but we still did it.
I still remember April 2020, when I intubated my first COVID patient. And after I had intubated her, I was in tears because I worried about her and I worried about myself and my girls. Yeah. So, a year later, here we are, again with delta, you know, spiking and people had access to vaccines and they don't want it. And you know, that's when you kind of realize that this is going to go on for years because the population just doesn't believe in the vaccine, they're worried about side effects. They're worried about death, especially with the omicron wave. That was interesting, that wave was the most interesting wave for the ERs, because it really, it was so contagious. And so many people came to the ER, and remember we still had delta circulating.
Yeah. So, we still had the delta patients coming in sick, and then we had all these Omicron, young, all age groups, just everyone had COVID. I remember one guy came in just to see if he had COVID so you can get out of a court date the next morning. But people were coming left and right. I couldn't believe it. Some people came and I was like, why would you come for this? There's you know, there were lines of people. We had no room, forget bedrooms and hall spaces. We were seeing them in chairs, in the lobby. I would have some of them walk to the x-ray or CAT scan department just to talk to them in private. Look for any area we could possibly just to see patients. That was the most overcrowded time, was mid-December to mid-January and you couldn't take care of patients. Physicians, medical staff, physicians were calling and yelling at the nursing staff. Like we sent our patient 5 hours ago, and you still haven't seen them. But nobody wanted to come down to the ER to see what mess we were in.
Dr Jin: You mentioned the nursing shortage earlier. When did that become a big issue for you?
Dr Patel: Yeah, mid-2021 is when we first started seeing our experienced staff, respiratory therapy, nursing start leaving for traveling jobs. And by the time Omicron came, we didn't have any more experienced staff. And we were actually very short-staffed.
Dr Jin: Do you think that was a contributor to your burnout?
Dr Patel: Yes. You know, just not having the same staff that I've worked with for five years, no longer there, that was a very large contributor as well. You know, I went from people knowing how to read my mind, knowing what orders to put in to people just, you know, not knowing. You know, we actually go up to our ICU to help out at night. So, if I went up to the ICU for 30, 40 minutes in the past, if I came down, orders were placed this time around, I don't notice that, you know, and sometimes now I have to say like, hey guys, try to just order something or get some stuff started while I'm gone.
Dr Jin: Yeah. So, your team and your community, that sense of teamwork and camaraderie was gone.
Dr Patel: Yeah. That, you know, just showing up and, you know, looking forward to people you work with was gone. So, I thought that the traveling nurses might just be a short term, but it doesn't seem to be an end. There just seems to be more of a growing demand. And people are getting enticed with the pay they're offering.
Dr Jin: And what, so what is the travel, the traveling nurses, what does that mean?
Dr Patel: They're leaving their salary, hourly jobs to be a travel nurse and filling up contracts. So, let's say they'll get offered a hundred dollars an hour, minimum 30 hours a week or 40 hours a week for 12 weeks. So, they'll just get up and take it
Dr Jin: Because they get paid more than working in the ER.
Dr Patel: Yes. And a lot of the nurses have, you know, they're making more than double, if not, definitely triple. I think some of the offers are.
Dr Jin: Wow. Yeah. I mean, we've heard about the travel nurses as, as well at, you know, in ambulatory practices kind of we're losing our staff to that as well, which yeah, I agree. It's a problem that spans beyond your specialty. So, do you think if COVID never happened, you would have still felt burnt out at this point in your career?
Dr Patel: I don't think so. I think COVID really brought out the flaws of society and you know, I don't, the nurses wouldn't have left. There would be no travel jobs, respiratory therapists there, everybody would have a set structure. Same with us, even our hours would be secured. COVID definitely brought out a lot of interesting. I don't know if you noticed those memes about, you know, how a lawyer can make $400 an hour, and a tattoo artist can bill for this, and all these other jobs that make higher salary or hourly. And yet, you know, people who can save lives won't even compare to what they make. You know, I make a joke with some of my friends, you know, who have a nice office jobs. I'm like, you know, especially when the CDC announced the five-day rule of, you know, if you're feeling better in five days, you can come back.
I made a joke about, to my office working friends, you know, you guys get COVID, you'll get the full two weeks off. You'll get paid time off. They'll even send you a nice get-well package. And for us, it's all right, here's your 5 days now come back and die. Part of the reason, you know, we need to return to work is there's no one else, same with nursing and respiratory therapy, but the way they go about it was interesting. You know, as I believe they started a research article that after five days you're really not that contagious. All of a sudden now with Omicron surge that comes out. And actually, the American Heart Association also came out with their guidelines about starting CPR before you put on PPE. So, both of those came out on the same week. And as you know, ER, we're always doing codes, we even do floor codes at night. So, I couldn't believe that that that's what they asked of knowing that when a COVID patient codes, there's less than 1% chance, more than less than 1% chance of survival.
Dr Jin: And massive exposure potential with that. So, I, you know, some of these problems, or actually, I guess, most of the things, the issues you highlighted sound like systems issues, do you, in your, you know, you're saying it's not the patients, it's not the job itself. It's just the system weaknesses that have been amplified by COVID. So, what do you wish could be done to fix that at this point? Is anything fixable? Is it just waiting, like you said, for things to calm down or what do you, what would be on your wish list of things to change?
Dr Patel: My wish list would be to have a more steady working staff environment. Regarding ER, I don't think anything can change. I'd like to be hospital employee. I would like to have normal benefits. Yeah. Oh, I would like the weekly hour changes not to occur. You know, there's always talk and I have a really good director who doesn't change my hours as much, or actually doesn't change my hours, but, you know, I also can't, you know, expect my colleagues' hours to be changed. A lot of places go monthly. There was time last year in 2021 where we had to make weekly change, or probably daily or weekly changes on hours just to see if the volumes were low. And, you know, we put a day set aside to go to work. We should get paid to go to work. ERs, we're there for emergencies, whether an emergency came in or not. We were there, we should not have an hour taken away or asked to leave early, just cause that patient population didn't come in or the patient's volume was not high enough.
Dr Jin: Yeah. I actually can't believe that you don't have set hours. That seems completely absurd to me that you can't make, you know, plans for, yeah, like for your kids' tuition or your vacations or whatnot. I mean, it just, as a working professional and saving people's lives.
Dr Patel: Yeah. We take a week off that's on our, we lose that week pay unless we make up those hours earlier or later in the month. You know, a lot of times people ask me why don't I take these days off ahead of time? And my answer is unless I have something planned, why would I? It's loss of money.
Dr Jin: You essentially have no paid vacation.
Dr Patel: Oh yeah. There's no sick days. No PTO, no vacation days.
Dr Jin: Yeah. That's, I mean, that seems like something to me that can be changed theoretically, you know, from a leadership or policy standpoint. So, Reena, do you feel like you personally have any power to make any of these changes?
Dr Patel: I have no power. We thought, we were hopeful 2020, the ER, my medical director really stepped up, you know. You know, figuring how to get employees tested, figuring out how to keep us all safe. And we had hoped that we can become employees of the hospital, but it's just, this is the culture now. You know, there's nothing that we can do from within. It's, you know, what happens for the ER, we're very close to who we work. I am really good friends with a lot of nurses at work, even some that have left. We still talk on the phone every week. And it's usually the same, x-ray, CT tech at night, you know, the same nursing every week that work nights. And we get very close to each other, and that's what helps us get through some of this.
Dr Jin: So, in terms of your long-term plan or the end game, where do you see yourself in 5, 10, 15 years?
Dr Patel: Same hospital. I actually enjoy the hospital. The administrators are very kind to the ER. I have a good boss. I'm not sure if he'll be there in five to ten years. I like the community I take care of. You do get close to it after being there for so many years, you really get close to certain patients. I'll still be here.
Dr Jin: Well, I certainly hope that in five to ten years there will at least be some systemic or organizational changes that will have been made to lessen your burnout. Thank you so much, Reena, for coming on to talk to us today. And this was so enlightening, I feel like, I don't know, just sharing your story. Not many people do that because they don't want to be vulnerable. They don't want to sound like they're complaining or negative, but I don't think that's actually what it is. It's not actually, you were not negative in the least. And I just think it was so interesting to hear your perspective these past two years and then overall in ER, as a field. Yeah.
Dr Patel: Well, thanks for having me.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward program is open access and free to all at stepsforward.org. STEPS Forward can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward podcast series, stepsforward.org.
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