Adam Interviews UMRC Emergency Medicine Chair Dr. Michael Kamali

Adam Interviews

ROCHESTER, N.Y. (WROC) — When talking about strain on local hospital systems, demand is only part of the conversation.

Staffing is the other.

URMC Emergency Medicine Chair Dr. Michael Kamali says his team has shrunk by about 20%, which mirrors what’s happening nationwide.

Dr. Kamali talked with Adam Chodak about why this is happening.

Adam Chodak: Why don’t we start off with your basic perspective on how things are going in your professional world right now…

Dr. Michael Kamali: Well, I think what everyone is experiencing across the country and somewhat worldwide with the pandemic is that it really has exposed some underlying difficulties that we have experienced all along, especially experienced in emergency medicine. And that’s been really exposed further with our staffing difficulties that we’ve been having of late.

AC: When did that begin?

MK: So if you take a look at emergency medicine, it’s a tough environment to work and takes a certain kind of person, but we’re having some burnout associated with that field because of how intense it is, is somewhat normal. So to some extent, we always had some staffing turnover that was the norm that we always experienced. But then during pandemic, people started to really get burnout a little bit. It’s been a long haul. It’s been exhaustion think. And naturally we’ve had some people who said I’ve had enough. And we’ve seen that across healthcare. We’ve seen that across all sorts of businesses and workplaces, but we’ve been facing it pretty hard, I think. And that makes the job at hand currently that much more difficult.

AC: I’ve heard that that burnout escalated, if you will, probably about 9 to 10 months after the pandemic started. So folks I’m speaking with, they’re saying it really started in their eyes January, February of this year. Is that about the timeline that you noticed as well?

MK: Yeah, it is. We started to see some erosion then and had a lot of people that hung out and, and still have a lot of people that continue to work in work hard, but started to see some erosion then and gradually slip away, got into the summer. Things were going okay, then really seemed to start to hit in the fall. This fall was particularly badly where a lot of people have said I’ve had enough, difficulties with everything that was going on with schools, with stuff and the anticipation of another search, knowing that there was likely another wave coming and that anxiety and stress associated with that, I think really made it difficult for a lot of people. And they said, I just can’t do this anymore. And a lot of the people stepped away from it. And when I say it exposed some of the underlying difficulties that we’ve always had in medicine, or especially in emergency medicine, I do think that it did, that we were always under quite a lot of stress. It was a difficult job to begin with and that much more difficult now. And I think there’s been a lot of stress for people from the standpoint of the difficulty in terms of trying to accomplish their job and be successful. So you take some additional people out of the workplace that puts additional burden on those who are there and makes it that much more stressful and difficult. So I fear even more people leaving and we’re working on strategies and things, what we can do to mitigate that while we are also working to do everything, to take care of all the patients that we do

AC: What impact do you think the mandates have had on staffing? MK: Well, so a lot of discussion about that for us in emergency medicine, or at least in our department here at Strong, we spent a lot of time talking with our staff, talking about the vaccine, why we felt it was important. All the science behind it. We had a lot of different seminars within the department and spent a lot of time talking one on one with people. So it had some impact, but I really feel that that impact was very minimal.

AC: Do you have numbers as far as the emergency staff goes, like the percentages or anything like that, that have left since the start of the year?

MK: So there’s some stuff that people are talking about nationally that maybe 20% of the healthcare workforce has left left. And I think for us in our department, it’s about that maybe a little bit higher than that. So it’s nothing that is way off from anything that is being experienced elsewhere. It’s very, very similar. But for us when you’ve been working hard all along and everyone in every field has been working hard, it just hits you a little bit because you do want to take care of every patient that comes through the door. And if people have to wait, that makes you feel bad. You want to take care of everyone quickly and provide them with everything possible.

AC: And then from my understanding, there’s a domino effect. Those who are left have to work harder, the hospital system has to bring in travel nurses. And that can complicate things if you wouldn’t mind talking about that.

MK: Sure. So the traveler nurses are an excellent addition, but also poses some problems as well. If we lose a nurse, someone that we’ve worked with for many, many years, we lose really significant experience. Someone that we know that we trust, that can really read our minds to some extent that when you’re dealing with a patient, knows exactly what to do and knows the system, traveling nurse can fill in and is a great help, but you don’t have that relationship that you might have had with someone else. And then there’s the cost associated with travel nursing that costs much more than a nurse that you have in the system. So that exposes to me some of the problems, maybe we need to look and give some thought to how we compensate our nurses, especially those in emergency medicine or those fields that are running 24/7. And I think about our ICUs and I think about our emergency nurses that really have been working very, very hard.

AC: You had mentioned earlier, the difficulty for a healthcare worker to look out at a field of patients and feel like maybe I can’t get to them the way I want to, or we can’t get to them as quickly as we want to. What is the crowding situation look like for you?

MK: Well, it’s tough. So there’s not a soul, not a person in our institution, uh, that it isn’t working their hardest to try and take care of patients, take care of our community and do everything that we can for our patients. And, and that’s up and down throughout the institution. Everybody is looking at every case, every floor, every bed, and trying to ensure that we can do everything possible for our, but we also know that the realities, that there are times where we have more patients than we have available space. So that’s where we try and think creativity, uh, creatively and look at what can we do? How can we take care of patients in the waiting room? What can we manage, uh, where are we gonna be in the future and what’s going to happen, but all of that causes some stress. So it’s not just us in the emergency department. It’s every aspect of every institution across the country. And it’s affecting everyone with, within the institutions, uh, as well because they, they see it. Our job, what we want to do is take care of patients. We want to take care of every patient that comes to the university of Rochester, and that’s no different than any other hospital across the country. We want to take care of every patient and provide them with everything possible. But the reality is that that that is not the case that we can’t always do that. So we’re trying to juggle, we’re trying to triage, we’re trying to take the sickest patients, first trying to manage those. We’re trying to work with our regional affiliates to ensure that they can manage the patients that they have in their facilities to ensure that we have space. But this is putting a big workload burden on those who are remaining here and who are working hard to manage it, but it also provides all of us a real sense of purpose. This is the game that we’re in. This is what we decided to do, what we want to do. And, and it keeps us going, keeps us moving forward. We wanna make a difference.

AC: Have you or anyone on your staff reached a point in the last few weeks where you’ve had to ration healthcare?

MK: So that’s, that’s a tough question to answer. And, and it comes down to, well, what exactly are you describing? So if there’s a patient that’s sick that needs a life-saving treatment, or there are two of those patients, we’re doing everything we possibly can to provide it to all those patients. What that means is if you have something that maybe isn’t as severe, you might be waiting a little bit longer than you would’ve otherwise. So everyone is working hard to provide everything we possibly can to any patient that needs it at any point in time. We haven’t reached a point and I’m hoping we don’t reach a point where we have limited ventilators or we have limitations on medications. Fortunately, we haven’t had that. We haven’t been forced to make those decisions, but we are trying to determine who’s the sicker person, how do we manage those that are very sick, those that aren’t as sick to try and provide care as timely as possible. And that can be a bit of a challenge and in a busy emergency department in a busy hospital. But what you do, you just keep moving through. What we are talking about is really, we can only see one patient at a time as an individual take care of that patient, ensure they have great care, then focus on the next patient and, and ensure that your colleagues are doing the same.

AC: Everybody in the in-depth Atlantic article that you and I have talked about. There was someone who pointed out that some hospital systems decided to cut salaries or benefits in the middle of the pandemic. And their suggestion was it should have been the reverse in order to keep staff. So A) have you noticed that where you are and B) do you think that could have helped with retention? MK: You know, I really don’t know. I think years from now, we will be looking back at all of this and have lessons that were learned. And decisions were made in the moment that decisions had to be made. I tend not to look back, try and think about it, and we don’t know what the alternative would have been. I think ultimately trying to provide a great place where people want to work and want to be and give them the ability to take care of patients is really what people in healthcare want. So that’s what we are trying to do. And I’m looking forward to our new ED which is still several years away, but trying to create that environment that is both very positive for staff and very positive for patients.

AC: And then long term , we’ve been talking about folks who haven’t gotten the preventative care they’ve needed over the last few years. Will you be seeing more of those patients? You have long haul COVID patients. I guess, what’s your fear going forward? Do you think you’re going to see more demand on the system?

MK: Well, that is a little bit of my fear, what’s going to happen here? So as an ER doc, we’re always wondering what’s around the corner. What’s coming in next and how many of those patients are we gonna have? How bad is this new variant going to be? How much more Delta are we gonna have? What’s going to happen with the flu? It’s unfortunate. We have a scourge of violence in our local community. That’s been really troubling for all of us and what’s going to be there. And how many staff are we going to have to deal with all of that? So I do think about that, but thinking and worrying about that also gives me a drive to try, to help me to plan and to talk with our colleagues in our department and in our institution to try to come up with some plans to deal with, with all of that. So it could potentially be very bad and get a lot worse. But I don’t ever see it as a point where it’s something that we can’t manage. We will continue to plow through and do everything we possibly can to deal with it. Yes, there are patients who have put off healthcare during the pandemic. We’ve seen that. And that is tough. Patients who can’t get access, let’s say things were closed down for a while, or patients who were too afraid to venture out because of fear of the virus or catching COVID. I understand that. So we are seeing some of those, thankfully most people are seeking healthcare and getting it now. But it’s still, I think for a couple years, there are going to be some reverberations related to this pandemic that we’re going to need to work through. So it’s going to be a long haul from a healthcare standpoint to get to the other side of this and to con continue to build, to make our systems work even better.

AC: Do you see a new crop coming up that’s going to be able to replace what’s lost? MK: I do. There is still a lot of interest. We for emergency medicine still have record interest in our field. But it does take years to get people through the system to fill in. So the same will be for our nurses, our nurse practitioners, our PAs, our docs, and really all of our staff. It takes time to train people and get people into the system. So there may be some lag there. I anticipate some people will come back to work in the nursing field. But I also think we’ll look at other ways. We’re trying to be innovative, think of things, look at technology. Are there other aspects and other angles that we can tackle this to help serve our community, but has been tough. I think it’ll continue to be tough. It’s really trying for a balance of being realistic, being positive, for the future, but also really being realistic. Okay. What is it that we need to do? How do we dig out of this? How do we continue to move forward? And for a lot of us, there’s no other option. This is what we want to do. This is what we chose, what we love. And we’re at a place where we feel that we can really make a difference. And so we’re fully vested there we’re fully vested to our institution and even more importantly, fully vested to our community to try and do everything we can. But with that being said, it is tough. There is a lot of stress.

AC: I know you’ve touched on this, but I’m just gonna ask it separate from everything else. Is there a certain degree of pride that you’re feeling when you walk in and you see the nurses and the doctors and the techs and the support staff still there working as hard as they’ve been working?

MK: Absolutely. There’s certainly certainly an aspect of pride. And I think people share that, more so privately. That’s what we do, it’s talked about, but there’s also the understanding and that’s the reality of it that a lot of people are struggling. This is very, very tough on a lot of people, people in the department, and in the institution, you mentioned the Atlantic article, there’s a line that struck me. People aren’t tired of doing their jobs. People are tired of the difficulty and trying to do their jobs. So people want to take care of patients, want to have beds for them, want to provide great care. It becomes tough when you feel they give so many patients, that you’re providing all of them with care that might not be to the highest standard you might like to do. And a lot of that is the comforts of providing blankets, pillows, beds, space, privacy, for those patients. And, and that’s the hard piece because we’re in this to give and to provide for our patients. And if we feel we can’t do everything possible for them. Well, that bothers us to our core.

AC: I have to imagine that for a lot of those who have left, that must have been a very difficult decision, given the devotion and dedication they’ve had for the job.

MK: I think so. So I I’ve talked to some people and I think for some people it’s really gut wrenching. And I think for a lot of people, that decision was that they just couldn’t go on any longer in the environment that the environment is tough. So that then comes back to me where I have to take a look at the environment, take a look at the workflows processes, all those things and see, can I build something that is more sustainable? And that’s what I think a lot of people are looking at and hopefully on a national level for our healthcare system, looking a little bit more at sustainability. And I also hope that on a national level, we’re looking at healthcare, especially the emergency medicine, ICUs, EMS, some of those frontline pieces of healthcare and viewing that as infrastructure and really needed infrastructure in our society. Um, we, it’s easy to talk about roads and that, well, the healthcare system is like a big highway and that highway was very crowded to begin with. We throw the pandemic on and take away let’s say some lanes and add a few more cars. Well, it makes it, uh, that much more difficult to get where you want to go. So we need, we expansion in the healthcare infrastructure to support patients and support the staff that are in it.

AC: My initial assumption was that those who left, you know, if they’re in a position like most Americans, they don’t have the money to support themselves for months or years on end, they would come back. And the response that I’ve gotten, so is that a lot of those who have left have been near retirement. So they have been able to hit that off ramp and stay off, which can create a lack of, or a depreciation of institutional knowledge.

MK: It absolutely. And that’s a big concern. And that, that’s what I said. When you have someone, a colleague nurse, doc, PA, anyone in the department that you’ve been working with for a long period of time. And we have a lot of them from our environmental services, our public safety officers, our techs, our secretarial staff that you’ve worked with for a long period of time. They know you they’ll come up to you with a concern with what have you, when you lose that, you lose a little piece of that, that trust and a little piece of that efficiency. We’ll build it back up with we’ll get there, but there are some people who have left healthcare who will not come back and that’s just the way it is as there are in other businesses where people have left, decided to switch gears, to do something else entirely, that is going to be the case. And that’s then incumbent upon us to innovate and come up with alternatives to care for the patients.

AC: Then we have on the flip side – do you expect some to come back once things settle down a little bit?

MK: I do. That’s my personal belief. I think we had some of our nurses who took traveler contracts that went around the country and, and certainly able to make some more money. And some of it, they might bring a excellent experience back, might all also see that the grass isn’t greener elsewhere, that other places are dealing with the same things that we have. So I do suspect that some people will come back. I also hope that we can formulate a model that works to retain people for even longer within the system. But with that, I also say we still have a lot of people who have been here for years and years and years who aren’t going anywhere who say, this is my home. This is where I am. I’m at the U of R I’m at the Strong ED. This is my community. And, and I’m here for a reason to take care of people here and they aren’t going anywhere. So it’s good to have that. It’s good for all of us to engage with them to ensure that they are as content as possible in the work that they’re doing.

AC: My last question for you, Dr. Kamali, is there anything the community can do to help you and your staff in this moment?

MK: Well, I think that’s a great question. So from my standpoint, it’s really talking to our government officials to look at healthcare as infrastructure and we need to expand, and our infrastructure, we’ve seen that in a pandemic, we’ve had difficulty with the amount of beds that we need. We should have extra capacity. We should have that infrastructure so that we can take care of patients. And that I think is what is desperately needed for all of us to look at healthcare in a little bit of a new light. I don’t have all the answers, everything that should or could be done, but I think we need to take a look at that a little bit differently, and this really has to happen at a federal level that we look at healthcare as to what it is, what we are trying to do, how we’re trying to take care of people. No one really thinks about when they get up in the morning that they’re going be in the emergency department. People might have a doctor’s appointment, a test, something of that is scheduled, that is normal. No one thinks about that. They’re going be in the emergency department and when they get there, if they have to be there, we want to make it as streamlined as efficient and as caring as possible. And for me, that requires some building of our infrastructure in the healthcare realm.

AC: Does this also apply to nursing care, given that what we’re hearing is that because nursing homes simply can’t take, or they’re saying they can’t take certain clients right now, those folks, a lot of them are being sent to the ER, where they’re be being boarded?

MK: Yeah. So it’s really multiple different factors that are coming into play here. That to some extent are creating if you will, a perfect storm of the difficulties that we’re facing in healthcare. So it has to do with the nursing homes has to do with outpatient clinics, it’s everything from phlebotomy to pathology to nurses to everything in between that the whole system has been placed under a fair amount of strain. So supporting that system and building that system, as let’s say, needed infrastructure, in my opinion, would help for the future to expand and create some flexibility or pliability to be able to absorb some of these variances that naturally come through.

AC: Very good, Dr. Kamali, anything that I missed that you’d like to add?

MK: Everyone in the hospital has been working endlessly to try and ensure that we are doing everything we possibly can. I don’t think that that can be overstated. The dedication that I have seen in the hospital these past two years is remarkable. And the vast majority of people continue to work very, very hard despite exhaustion to take care of both one another, but also the patients and the community in this extent, Strong takes patients from hundreds of miles away. We view that as our purpose with our specialties and all of that. So a lot of really hard work. And what we are experiencing here is being experienced across the nation. This is not unique. This is not a Rochester problem. This is an American healthcare problem that I hope we can give some thought to and to try and work through in the coming years to build a system that functions a little bit better for patients

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