The Evolving Critical Care Workforce Crisis: Women Leaders in Critical Care, Ep. 2

This podcast series aims to highlight the women leaders in critical care medicine. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.

Episode 2: Moderator Jaspal Singh, MD, MHA, MHS, interviews Meeta Kerlin, MD, MSCE, and Sue Stempek, PA-C, about the critical care workforce crisis, how the COVID-19 pandemic affected this crisis, and how being a woman leader during this time has impacted them professionally and personally. 

Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.

Meeta Prasad Kerlin, MD, MSCE, is an assistant professor of medicine at the Hospital of the University of Pennsylvania, associate program director of Pulmonary and Critical Care Fellowship at the University of Pennsylvania, associate scholar in the Center for Clinical Epidemiology and Biostatistics, and senior fellow in the Leonard Davis Institute of Health Economics in Philadelphia, Pennsylvania.

Susan B. Stempek, PA-C, is a physician assistant specializing in Pulmonary & Critical Care Medicine in the medical intensive care unit, director of Advanced Practice, and capacity management provider in the transfer center at Lahey Health and Medical Center in Burlington, Massachusetts.

TRANSCRIPT:

Jaspal Singh: Hello everybody, I'm Jaspal Singh. I'm a pulmonary and critical care physician at Atrium Health in Charlotte, North Carolina.

With me today for the second episode of the Women Leaders in Critical Care series is Dr Meeta Kerlin from the University of Pennsylvania and Sue Stempek from the Lahey Clinic. So, Meeta, let’s start with you. Can you introduce yourself, please, for the audience?

Meeta Kerlin: Sure. Hi, thanks for having me. My name is Meeta Kerlin, and I am a pulmonary and critical care attending at the University of Pennsylvania. I'm really delighted to be here. My research focus has been in thinking about ICU organization and outcomes in implementing best practices. So, I'm delighted to be here for this talk today.

Jaspal Singh: We're glad to have you. Thank you for making the time. With me also is Sue Stempek. Sue, do you want to introduce yourself as well?

Sue Stempek: Thank you so much for having me. I am a physician assistant working in the medical ICU at Lahey Hospital and Medical Center. Some know it as Lahey Clinic.

I am also the director of advanced practice here in our organization, and I am also a capacity management provider leadership role for our Transfer Center. I'm delighted to be here and talk about critical care resources with all of you.

Jaspal Singh: Great. Some of you know there's a big passion of mine. It's great to have both of you on here. And both of you for all the great work you've been doing in the space.  And so, Meeta, we'll start with you.

One of the things I've been very interested in is, even before COVID-19, our country for the last couple of decades has been evolving into this critical care crisis related to the workforce, related to ICU resource utilization. Talk to us about what that looked like historically and what the challenges were, if you don't mind, and frame this problem for us today.

Meeta Kerlin: Sure. This is obviously a topic that's near and dear to me as well. I think maybe one thing that you're referencing by saying a couple of decades: Back in 2000 there was a big study that was published by Derek Angus and colleagues in JAMA—the COMPACCS study

That was, to my knowledge, the first big projection of this workforce crisis among intensivists. I think at the time that crisis was only just beginning to be sensed or maybe realized; demand and supply were relatively matched.

But this group projected that they would diverge greatly in the coming years. This got a lot of press, as I understand it. At the time, it prompted a report to Congress by HRSA (Health Resources and Service Administration) and a lot of concern over what we were going to do.

I think some of the issues that were key here was prior to about 2000 prior to that time, less than about a third of patients in ICUs were actually cared for by intensivists. Critical Care was not the specialty that it is now, but there was a growing understanding by then that intensivist-led care may improve patient outcomes. And so, there were going to be shifts in demand in the future.

Not only because we had a growing population of elderly patients—the Baby Boomers—were going to become elderly and more likely to develop critical illnesses. We also had advances in medicine that were saving more lives, but these lives may also go on to require intensive care eventually.

And then of course what I started this with, more and more hospitals may shift to ICU-staffing models that require more intensivist staffing. I think all of these were incorporated into these projections.

Jaspal Singh: That is an excellent start. And I think this has helped shape my career a lot, a lot of my professional interests. Derek Angus’ work started, I think, looked at these issues with a much more critical eye. 

And we've seen this evolve. Several strategies over the years have been deployed to address the crisis. One of them is expansion of the workforce. So, with that, Sue, pre-COVID-19, if you could talk to us a little bit about this. You have a lot of experience developing the additional work forces that we've involved in ICUs. Since critical is a team sport, one of the key workforce strategies has been expansion of advanced practice providers or APPs, PAs, and NPs. Can you talk a little bit about that and how that's shaping up around the country and what you all have done?

Sue Stempek: Yeah, I have both experience with this in private practice as well as at an academic medical center. What I can say is, years ago in private practice, we recognized the workforce challenges. I had worked at a multidisciplinary private practice that was serving multiple hospitals in metro Atlanta.

We recognized that it was very challenging for the physicians in their call schedule to be at the bedside of critically ill patients in a 24-hour model, serve the demands of the office practice, perform bronchoscopies, and all of the other attending-based demands on their time.

And so, we had a group of physicians who recognized that this was not a palatable state and had a few of us work on a training program. This was years ago before APP fellowships were popular. But at the time, we were very proud of coming up with an innovative design of training APPs specifically to be that “boots on the ground” bedside provider as an extension of the physician.

And that worked really well, as we trained people to be very good at central lines and arterial lines, other procedures, although we did depend on the in-house anesthesiologist for intubations for the most part. But it was really able to provide evidence-based critical care in a 24-hour model that was much less possible before we were doing this.

Based on that experience, as I came to Lahey Clinic, we had a very robust APP critical care program even when I came here, but I recognized that we probably needed to augment this. Actually, a large part of our program here is the extension of critical care outside the ICU. We have APPs in our ICU but also recognizing that critical care consults are, of course, a 24-hour thing.

Providing the attending physicians with the ability to focus on rounds and efficiency, while using the APPs to be able to respond to our rapid response calls in critical care consults, was also a very efficient model.

I think the application of APPs as an augmentation of the workforce may look different in each setting based on resources and demands on the critical care time, as well as the patient population. There is some iterative work at the organization level, but some principles that probably apply in most places.

Jaspal Singh: That's well said. That's very helpful as we think through this. Meeta, do you have any comments about this idea of building capacity through additional workforce? Or what are some other things that potentially you think might have helped develop capacity, as you might say, even prior to COVID-19?

Meeta Kerlin: Yeah, I think it's absolutely necessary. So, we have limits on the critical care intensivist workforce, critical care physician workforce, that are based on how many people we can train. Maybe we're going to be talking about burnout before this podcast is over.

But there's a lot of turnover amongst critical care clinicians for good reason. And so, I think that building capacity in innovative and creative ways is absolutely important. The APPs, as Sue has discussed, have been a huge advance in our field.

I think there have been some other things that have advanced our field. Telemedicine is an example that comes to mind, both in the pre-COVID era and very much during our pandemic as well in my experience. Utilizing intensivists to be able to reach more patients, maybe more in a consultant role than in a primary role, I think that there's a lot of potential there. I don't know if we've seen the promise achieved yet, but I think that there's a lot of potential innovation there that I'm interested to see.

Jaspal Singh: That's great. If I hear you both right is that basically, there have been growing challenges in meeting the demands of critical care. The discipline itself has been changing. There's a number of different pressures and constraints. And then also, that in the background, we've been working at building capacity in various shapes and forms through telemedicine, through APPs, and other system design.

But along comes COVID-19, and suddenly, the system is stressed, and every system has been stressed in some degree. I was wondering if you can talk to us a little bit about what you just framed—this critical care crisis—and what the stressors are today that we've done and what we possibly are doing to meet those challenges, especially in your own institution? We’ll start with you, Sue.

Sue Stempek: As many organizations have, I think we've all done some work in some way or another to augment our critical care workforce. For us in our organization, that was very necessary in the spring with a very early and significant surge and then we were able to take a break on that work in the summer and early fall. Now we're back to it.

I think that the lessons that we learned in the spring in metro Boston, where we had a very early surge compared to a lot of the country, was that the idea of advanced training for this flexible workforce—I referenced the APPs specifically here—it was super important.

We were able to provide some “just in time” training for that workforce to help augment the critical care staff, but we actually found that the critical care, intensivists, of course, and the APPs who critical care was their primary job were also able to be very much “at the elbow” support for these redeployed providers.

Then what we did over the summer is we iterated on that experience and said, “Why don't we look for some true volunteers who want to go through some training, not to be a critical care APP necessarily for their whole career, but to be better prepared with more in-depth training?”

We created a rotational experience in our medical and cardiac ICUs so that these APPs could rotate from their primary job, which was a sacrifice for their home division, to learn about critical care, especially focused on ARDS, shock, and renal failure for us—is how we shaped the training.

And then we have them rotating on a monthly basis to be prepared for that redeployment. In fact, at the time that we're recording this podcast, we're probably about to do that redeployment and to see how it works. So, I'm hopeful that we will have learned a better way to train people in advance of redeployment, recognizing that it's not an optimal scenario for anybody.

I think we've always known that APPs are a relatively flexible workforce, and this is probably iterating even more on that than anybody ever thought was possible.

Jaspal Singh: That's great work. Meeta, what are your thoughts? It's a very complex topic, I recognize, but love to hear your thoughts on the lessons of what you've been working on.

Meeta Kerlin: We did a lot of similar things where we asked and really, I would say, got a great response from a lot of different groups who are not intensivists. It's by background to help and people that were very willing to step up, whether it be retrained or work on teams or whatnot. I think that we had a lot of different creative solutions.

I work in a hospital system that's actually 6 different hospitals. There was a lot of sharing of information across the different hospitals at the leadership level, which I think went a long way as well.

I'll say that one of the things that was most remarkable was the ready deployment of these team models that were unique. What I mean by that is, for example, in the in the nursing groups, there would be teams of critical care nurses with noncritical care nurses or medical intensive care nurses with, say, neuro-intensive care nurses—people who had different backgrounds but complimentary ones where everyone was practicing at the top of their training and their license and supporting the needs of patients in the ways that they were capable of. And I thought that was really remarkable.

We also did that actually at the intensivist level. For example, I worked in an ICU back in July. As we were coming down from the first surge in Pennsylvania, we had 2 teams. I was the attending for one team. and a cardiologist was the attending for the other team. He wasn't an intensivist, but he was interested and wanted to help.

He asked me if there were ICU questions that he maybe wasn't as familiar with, but it extended my expertise as an intensivist to twice as many patients as I would have otherwise been able to have. As we are thinking, we too are just in the past week have reconfigured our ICUs again to be able to accommodate more COVID-19 ICU patients. We’re definitely feeling the surge again.

We're redeploying some of those team models, which I think have been very supportive and allow people to help where they can but not feel overwhelmed.

Jaspal Singh: That's very helpful. So, Meeta, let me ask you something that's really near and dear to my heart. We did a very important publication on the idea of nighttime staffing by intensivist and found it did not change outcomes. I'm wondering how you put that into context into today is that a different frame? Or are you using that knowledge to frame how you’re staffing and building your teams, if you don't mind my asking?

Meeta Kerlin: That's such a great question, and one that I think about a lot. I think there are only so many outcomes that have ever been published when we talk about the literature on nighttime staffing.

We've been very focused on singular things that are often very patient-centered—mortality, length of stay, and things like that. Those are, of course, important, and they're hard clinical outcomes, but they do not tell the whole story.

I don't actually think that they can fully apply to where we are today in the pandemic, because it's not only about patient outcomes, though I think that's obviously a huge part of what we need to be working toward.

But we also need to be supporting our workforce here. In a model where you may have a lot of people at different times of day that are not necessarily trained intensivists or trained in critical care, having that extra layer of support is going to provide a level of comfort and situational control—that's an expression that one of my mentors has used to describe this—that I think is probably unmeasurable but absolutely critical right now.

Jaspal Singh: I think that’s really well said. That's a nice segue into thinking about … situational control makes me think about all the stressors involved. I think that I could probably speak for both of you that this has been a very stressful year so far, and the year is not even over. It's just building and mounting in terms of stresses. First of all, how are you all doing? And how are your teams doing?

Sue Stempek: Thanks for asking. I think I'm doing fairly well given the circumstances. What I can say, and since this is a critical-care-centered conversation, I think it's okay to say here. I think critical care providers are very unique people.

One of the most heartwarming things for me as a critical care provider, as I've navigated both our incident command structure and different leadership roles in that as well as being a clinician and also partnering with people who are being redeployed who are very anxious about that, is we support each other really well as a community in critical care. That has just been validated for me over and over and over. I feel very thankful for this to be my clinical subspecialty in how we navigate this.

I think the converse of that, of course, is that this specific disease has been our burden. Since March, we've all been managing those probably more than other groups and clinicians, for the most part. I don't mean any disrespect to other specialties, but I do think we have found ourselves bearing this burden the whole time. We've not had a break. We've not left the ICU. We've still had COVID-19 patients, and even if they're not all in the ICU, we're worried about the ones that are on the floor.

Our volumes have fluctuated, but the burden has remained on the critical care teams. I think those have risen to the occasion, but I do consistently worry myself and for my team that I work with clinically that we all are just worried every day about supporting each other and supporting our colleagues who may need to be redeployed and are less familiar. That burden of making them comfortable sits with us as well.

And so, it's not a terrible thing. It's just the worry that we bear every day.

Jaspal Singh: Meeta, how are you guys doing?

Meeta Kerlin: That was so beautifully said, and I echo all of that. I think we're doing okay.

We had a difficult period with the first surge, but we were able to manage as a team. I think because everyone had such a team-oriented mentality, both amongst the within my division amongst the clinicians and the APPs and even more broadly within the ICUs. People are there to take care of each other.

I totally agree with you, Sue, that our specialty is one where people run toward the challenges, not away from them, and I'm so grateful for that.

I, too, worry about how everyone is feeling and managing with the second surge. A lot of us probably hit pandemic walls over the summer even. It was great to have a bit of a respite, but we're all worried—I'm worried—for our teams going forward for the next few months. I think everyone will get there and prevail, but we have to just keep supporting each other.

Jaspal Singh: Yes, that’s very hopeful. When you think about this—what you've been through and what you’ve gone through (sigh). Thank you both for your responses, this podcast is also about women leaders.

As women, are their unique aspects of this story that you would like others to know about? Whatever you feel comfortable sharing with us, but I'm sure our listeners would love to hear how you're managing this particularly as women leaders.

Meeta Kerlin: I think I face a lot of the challenges that many women, and men, are facing right now, which is balancing professional responsibilities, fear of getting ill, or getting my family ill with personal responsibilities, having young children at home, homeschooling, and all of that. It's a lot.

I don't know that it's necessarily specific to me or to women leaders, but it's a lot for all of us to manage. I think professionally as a researcher, it's been challenging to figure out where the research is going to go. So many studies were put on hold. I was meant to start a trial that was put on hold once around May and looks like it's going to be put on hold again now.

These are realities that we have to think about and deal with. At the end of the day, I think that—again, not to be repetitive—but just seeing how teams have come together to support each other in all of these different fronts has been amazing and what keeps us all going, I think.

Jaspal Singh: That's very nicely said. Thank you. Sue?

Sue Stempek: I certainly can echo a lot of those things on both a personal and professional level. I think I would add, too, that I do worry a bit uniquely about women leaders. I think societally we still have some opportunity to better support the growth of our women leaders.

We all know from what we see in the popular media, as well as in some studies, that the effects of the pandemic and how we've had to navigate our personal and professional lives may affect women disproportionately. For growth of leadership opportunity, that may be an additional barrier that, pre-COVID, women weren't having.

I'm very fortunate to personally not be in that situation, I don't think. At least, not that I can see with my own eyes. But I'm aware that that may be true for some women leaders.

The other thing I would add is that I've had a unique experience being a physician assistant at a higher role in our incident command structure, which has been an interesting experience for a number of reasons in a good way. My organization has put the faith in me to be in the role. But the reporting structures are quite different than our day-to-day operations.

So, I think in some ways do I look at it as, potentially, a way to break some barriers that otherwise would be out there, and we never would have had these opportunities to think this way or to look at each other in that light. I think there may be some positives that come out of this.

The other side effect for, unfortunately, sometimes especially women is maybe we've learned, especially in medicine, a little bit about how to work remotely. We were never good at this, compared to other industries, and maybe we’ll become a little bit better. Obviously, when we work clinically in the ICU, that's a little bit challenging. But in a lot of our research or administrative work that we do, maybe we will become a little bit more friendly to each other when we have our living room in the background.

Jaspal Singh: It's really well said. I think there are a lot of good points in there. It sounds like you're also hopeful for the idea of teams working remotely, getting to know each other that way, working together collectively towards opportunities professionally for growth. Hopefully the country is now paying attention to that perspective.

Meeta, I assume you're hopeful also that there will be some adjustments in the promotion pathways for women as well with the current pandemic. I don’t know if you can talk a little bit about that, because that's getting a lot of national attention recently.

Meeta Kerlin: Yeah, I think that is an important point. And I love the points, Sue, that you brought up that that maybe we're working toward a way in which the work environment can be a little bit more friendly and flexible for women physicians, women leaders who need that.

So I, too, am hopeful. I think that a lot of attention is being paid to things like academic promotion and giving women in general and everyone some support and credit in this time and recognizing just the impact that COVID-19 is having on people's careers and their career trajectories.

Jaspal Singh: Well, I want to thank you both. I want to ask you both really quick. If you can leave our audience with one thing that you’re hopeful for moving forward.

Sue Stempek: One of them is a thanks for people like you to be providing a lens on the unique position that women leaders in medicine, especially as it applies to our specialty in critical care.

I think that we have new opportunities in the pandemic and with leaders like yourself to provide a platform to bring these things forward. So, thank you for that.

The other thing I'll add myself that I feel very strongly about is we have turned our world upside down in the last 10 months and—I can tell that we're both motivated by this—we should not let that opportunity go to waste. We should continue to push our organizations, especially administrative leaders, to provide the space for us to benefit from that innovation.

My own commitment, as we hopefully someday come out of this—not exactly sure when—is we don't let those learnings go to waste and that we also push the organization to provide this type of platform. Because we never had the opportunity to iterate so quickly in a hospital before. I think we can all be very proud of what we've done at the bedside on behalf of our patients, and I would love to continue the opportunity to efficiently do that.

Jaspal Singh: That's really well said, Sue, thank you. Meeta, what are you hoping for?

Meeta Kerlin: First, I'll just echo that “thanks.” This is really such a unique and wonderful opportunity, and I hope that this starts a new era in highlighting and bringing forward the important roles that women play in leadership in medicine.

Just to jump off of what Sue just said, yeah, let's make sure we take the good that has come out of this really, in many ways, horrible experience that we've had for the past year and make life better later on. I'll go back to the team models that I see growing up everywhere.

I really have never seen such positive collaboration across so many different people, often who barely know each other, as what I've seen in the COVID-19 ICUs in my experience in the past 10 months. And so, I hope that that's a new model for care going forward.

Jaspal Singh: Thanks to both of you. That's really well said. And this is Jaspal Singh from Consultant360. I have Sue Stempek with me from Lahey Medical Center and Meeta Kerlin from the University of Pennsylvania health care system. And I just want to say thank you to our guests today for a phenomenal and inspirational talk on Episode 2 of Women Leaders in Critical Care. Thank you so much for your time.

Sue Stempek: Thanks for having me.

Meeta Kerlin: Thanks again, take care.