Life in a rural emergency department during COVID [PODCAST]

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“I am grateful that I work in a small rural hospital that is like a family. I am grateful that my organization has done everything in its power to protect us… but I hope we can do better. I hope medical workers have enough left within them to give their all for the coming months. Now we are in November with cases on the rise throughout the country: I hope we are more prepared. As the medical community, we do everything we can to protect our patients, our loved ones, and ourselves. Life in the emergency department during COVID has been some of the most emotionally and physically taxing of my career, but I remain optimistic that there is hope.”

Andrew Tisser is an emergency physician.

He shares his story and discusses his KevinMD article, “Life in the emergency department during COVID: a rural physician’s perspective.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Andrew Tisser. He’s an emergency physician, and he wrote the KevinMD article “Life in the emergency department during COVID: a rural physician’s perspective.” Andrew, welcome to the show.

Andrew Tisser: Hey, Kevin, thanks for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and your journey to where you are today?

Andrew Tisser: Yeah, thanks. Like you said, I’m an emergency physician. I’m practicing out in the western New York area. I went to school at the New York Institute of Technology College of Osteopathic Medicine and did residency in Syracuse, New York. Nowadays, again, I’m living outside of Buffalo with my wife. I also host a podcast myself, the Talk to Me Doc podcast, and I’m a career strategist for physicians who are dissatisfied with their careers.

Kevin Pho: All right, tell me a little bit about that. What made you decide to go into that non-clinical realm?

Andrew Tisser: Yeah, I mean, it’s still mostly clinical, don’t get me wrong. I think I struggled a lot when I first got out of residency. People talk about burnout as it pertains to 40-, 50-, 60-year-old doctors, but I experienced it almost immediately. And all my more senior colleagues said, “Hey, you’ll get over it.” I didn’t find that to be true, so for an escape plan, almost immediately, I looked at the lists of other careers and tried a lot of different things, and I didn’t really find anything that spoke to me.

So I worked with some mentors and some coaches, and I was able to craft a career I enjoyed. I then helped a lot of my colleagues and friends do the same, and eventually I started a business around it because, frankly, I was good at it. So that’s where we are today, but I still spend most of my time chugging away in the ER.

Kevin Pho: Now, what were some of the things about the physician life that you got out into that you were dissatisfied with and that potentially led you to burnout?

Andrew Tisser: I think there’s always this “it’ll get better” delayed gratification as you move through your career. Medical school is medical school, and then you’re working to try and get into a residency. In residency, it’s really challenging, the hours are terrible, but it’ll be fine once you’re out there. And when I got out, it was just even more pressure: the pressure to produce, the pressure to perform under really stringent metrics. Honestly, some of the places I was working were expecting me to see four patients an hour, which frankly is not safe. And just the lifestyle of an emergency physician, with all the nights and weekends, coupled with just a really terrible work life, really, it was a recipe for burnout right away, honestly.

Kevin Pho: Now, for those other emergency physicians who may be listening to this, what are some tips and advice that you can give them?

Andrew Tisser: Sure. I think the first step is to cut down. You’d be surprised at what dropping one or two shifts a month will do to your lifestyle. And if you look at it, we’re all high-tax-bracket people here. The change in income might drop you by a tax bracket, so you might not be feeling the hurt so badly. But I really would suggest cutting down your hours as a first step. It also gives you some time to do some deep work and try to figure out what you want to do, if that’s not it. Emergency medicine lends itself to almost any schedule you could think of, if you’re doing employed, locums, or multiple different facilities. It is a specialty that gives us a lot of flexibility.

Kevin Pho: All right, so let’s transition into your KevinMD article. You wrote this back in November. It’s titled “Life in the emergency department during COVID: a rural physician’s perspective.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Andrew Tisser: I wanted to bring light to some of the challenges we face in the rural community. I live in New York State, but we certainly did not have the surge that New York City did. But we were feeling all the fear and anxiety around it. I think I start the article off with asking my wife, “Should we get a will together?” Because when the stories were first starting to come out back in March of 2020, frankly, I was terrified, and I wanted to say that in the article as well. A lot of us were just looking for masks and respirators and things online and putting together legal documents, because, right, if you’re looking at all the stuff coming out of New York City at the time, all the people dying, all the health care workers dying, yes, I was young, but I was scared.

And then the other part of the article is that we didn’t get the surge. We prepared well. I thank my organization; they did a great job. But then when the November surge came, we felt that for sure. I direct an urgent care, and our volumes increased by almost 120 percent, so that hit us. And at that point, people were really still doubting the validity of the pandemic. I was hearing comments like, “I hope you were right about this, Doc,” or, “This seems like a whole lot for nothing.” And those comments are, A, disrespectful, but B, after everything we had been through as health care workers, doctors, nurses, RTs, everybody together, over the last number of months, it stung more than many can really understand.

So that was kind of the purpose of my article: to talk about the rural perspective and talk about how we were feeling in November, and then to say we were starting to feel some hope. And that was even before the vaccine rollout started.

Kevin Pho: Now, can you share a story or an anecdote about some of the challenges that you face in a rural emergency department that urban emergency departments may not run into?

Andrew Tisser: Part of the issue is just the size, right? I work in a small, very small ER. We see about 25,000 visits a year, and our ICU capacity is nine beds and flexes to 12. In the big cities, also, you happen to have a lot more hospitals in the geographic area. A lot more people, but a lot more hospitals. So we see people coming in who travel a half hour, 45 minutes by ambulance to get to us, and at that point they can be quite a bit sicker.

Also, as far as the large hospitals that we transfer people to when we can, if we don’t have the specialty or if the people are too sick for us, they were at capacity. So when you run into an issue where you can’t transfer out patients you normally transfer out, it’s a big bottleneck effect, and it drips down to the ER. And then we’ve got to see everybody who walks in the front door. And of course, overcrowding is a big issue for anyone, but at least at a facility that has a lot of resources. We’re a small hospital with a small staff, and we just do the best we can.

Kevin Pho: Sure. So tell me about what kind of tertiary care backup you have. Are there some things that you can’t do or can’t handle at a smaller hospital emergency department that larger ones can?

Andrew Tisser: Yeah, my hospital is nice in that we’re a small hospital that is part of a larger system, so we have two big hospitals that we transfer patients to. And yeah, I mean, there are plenty of things we don’t have. For example, I don’t have a neurologist, so strokes are all transferred out, basically. We don’t have any PCI capability, so we’re still using thrombolytics in some of these STEMI patients and then shipping them out. So there are a lot of specialties we don’t have, plus we don’t have the ability to necessarily call in ENT for something, or what have you.

I say it’s challenging to work in a small ER, but it really improves your skills, because you’re doing a lot more as the emergency physician. At night, I’m the only proceduralist in the hospital. It’s me and the internal medicine hospitalist, and that’s it. So I like it, I think it’s great, but certainly you’ve got to use your resources well.

Kevin Pho: We’re talking to Andrew Tisser. He’s an emergency physician, and he wrote the KevinMD article “Life in the emergency department during COVID: a rural physician’s perspective.” Andrew, what do you feel are some of the challenges facing rural emergency department care going forward, even after the pandemic, in the next year or so?

Andrew Tisser: That’s a good question. I think staffing will always be an issue. I think it’ll be an issue for the large and the small hospitals. You’re seeing a lot of the freestanding small hospitals getting gobbled up by bigger systems just because they can’t survive. I think the challenges, of course, will be continued staffing and vaccination rollout programs. Luckily, we were able to do that well. But I think, as some nursing and some other specialties seem to be leaving medicine because of burnout and other issues of that nature, staffing will continue to be an issue.

Kevin Pho: And for those newly graduated emergency physicians looking for new jobs, what are some character traits that they should have if they’re considering a rural setting?

Andrew Tisser: You need to be comfortable working on your own, which, coming out of a big residency program, you call a specialist for anything, right? And there are a lot of things that perhaps we can handle as emergency physicians that don’t necessarily need transfers and would be inappropriate transfers. So being able to utilize the resources that you have, and being able to form close relationships with the nursing staff and the other staff, because there’s just not a lot of you. I know everybody by their first name, and they all call me by my first name if they feel comfortable, so we’re kind of like a family.

It’s hard work. You see low volumes and you think, “Well, oh man, I could see a patient in a half an hour.” But again, your skills are kind of put to the test. So I always suggest getting experience in a lot of different settings. That’s what I did when I got out, and I just liked the smaller hospitals. But just be prepared that it’ll put your skills to the test.

Kevin Pho: And after working in the rural setting for a few years now, is there anything that you know now that you wish you knew back before you started?

Andrew Tisser: No, I don’t think so. I mean, I think emergency medicine has changed as a specialty over the years. It’s certainly become more data- and metric-driven, which is just medicine in general these days. I was fortunate: When I got out of residency, I worked at multiple different facilities, from tiny to huge, in an effort to really figure out what I liked. So it’s important to understand what you do and do not like, because that’ll help you shape your career. And not just, “I hate working in the clinic,” let’s say, but what about that? Do you hate seeing a million patients an hour? Do you hate being on call? Do you know, specifically, what you do not like about what you say you don’t like? That is really important for anyone at any stage of their career.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Andrew Tisser: I want to make it clear to physicians and everyone else listening out there that you have endless possibilities when it comes to career design. We see this very linear movement through your career, from medical student to resident to attending, and a lot of people say, “Well, what’s next?” when they get out, right? And there are so many possibilities. You just need to figure out what you want out of your career and then work backwards to try and design it. It’s out there; sometimes you just have to be creative. So you could design almost any career you want.

Kevin Pho: Andrew, thank you so much for sharing your time and insight, and thanks again for being on the show.

Andrew Tisser: Thanks, Kevin. Really appreciate it.

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