Arjun Venkatesh, M.D., M.B.A., M.H.S., is an associate professor and chief of the section of administration in the department of Emergency Medicine in the Yale University Department of Emergency Medicine, and 2020-2021 National Academy of Medicine ABEM Fellow.
Dr. Venkatesh recently had the opportunity to share his experiences with ABEM. In the interview below, Dr. Venkatesh was asked to reflect on his experiences as the NAM ABEM Fellow and as an emergency physician.
What effect has the National Academy of Medicine fellowship had on your career?
The National Academy of Medicine fellowship is a really special opportunity for emergency physicians. The National Academy of Medicine itself is sort of the institution of all institutions when it comes to health and health care in the country. ABEM is obviously the standard bearer for so much of Emergency Medicine, so, you put those two things together and it’s a real opportunity as a young emergency physician, to get to participate in the meetings and the committees and the work at sort of the highest levels across the country. As for my career, it has allowed me to expand my network beyond Emergency Medicine, particularly at the time of COVID-19, to people I couldn’t have imagined working alongside: leading neurologists from around the world, people involved in disaster preparedness, flu and pandemic response. In many ways, it’s opened my eyes to a lot of different academic and policy opportunities that I wouldn’t have known of before. It’s also helped me launch into some of those areas in a way that is different than working as an emergency physician or being in an academic department.
Can you provide me a brief synopsis of the research that you’ve been conducting while you’ve been a fellow?
I think one of the things that’s been nice about the research that I’ve conducted as a fellow has been that it’s been with full freedom. I’ve had a chance to play with some datasets and look at some trends that I’ve noticed on the ground in the emergency department but haven’t had either the grant or the space or time to be able to really explore. One project we’ve done is to look at hospitals over the last decade and where they are located, and what is happening in terms of hospital and emergency department closures, and how’s that affecting access to emergency care. The analysis we've finished shows that in many ways, there are EDs closing, and yes, many of them are closing in rural communities, but not at the alarming rate that some news reports might show. What is a bigger issue, though, is that the same number of EDs are caring for one and a half times as many people in the last decade. And so EDs are getting crushed by the tsunami of new patients as people seek access to care. That has been an interesting finding, and an interesting analysis. I couldn’t have done this sort of study without this fellowship.
What do you value most about a ABEM certification?
I first became board certified in 2012, when I finished residency. I think ABEM certification to me carries a couple things. One, is that as somebody who’s in a more administrative and leadership role in Emergency Medicine, when we are looking to hire physicians, hire fellows, support those fellows, it’s increasingly clear to me that ABEM certification is something that is a known entity, how trained and how prepared and how ready someone is as an emergency physician to work in your ED. That’s the internal thing I think about. Externally, I think even board certification is important within the house of medicine. There’s always going to be numerous discussions and dialogues and rapid transformations when it comes to things around the scope of practice, the skills and abilities of physicians to work in different environments. And Emergency Medicine is hard. We work all day, every day without the conveniences that many other specialties may have. And so to have something like board certification that can help establish a standard instead of scope of practice for us, I think is essential when you want to think about having people prepared to negotiate with hospitals and credentialing staff or states and under different policy circumstances to make sure that we can practice the fullest of our training and abilities.
What drew you to Emergency Medicine as a specialty?
As a second-year medical student, I was convinced I was going to be an ear, nose, throat surgeon. I went to medical school at Northwestern, and we had a course called physical diagnosis, and I was assigned a mentor, Mike Schmidt, in the emergency department at Northwestern. Between Mike Smith and Jim Adams, who was the chair of the department, over the course that year, I had the opportunity to come down to the ED once a week and learn how to use a stethoscope, and really learn real medicine, not out of a book anymore. And I caught the bug. In the course of just a few visits that of the day I said, “Wow, this environment’s unique.” And it became clear to me that this was the place in medicine where you get to make real diagnoses, where you get to have a real impact in people’s lives, because you were trying to help them on, what for many people is the worst day of their life. That there was such sort of variety, a real opportunity and challenge and engaging with people. There was a team atmosphere that you don’t really see in many other aspects of health care, and all those things grabbed my personality and grabbed my curiosity, and I don’t think I ever looked back.
I’ve heard very similar stories among physicians that once you get exposed to it, you’re never turned back.
Yes, I think the thing about Emergency Medicine now as I work with medical students, is to tell them that in first couple shifts, you’ll know if this is for you or not. I think there are other specialties where people do a rotation for four weeks and they still are struggling to know if it’s for them. They can’t really imagine what the life of the attending is like, versus the student. Emergency Medicine is the exact opposite. Nobody ever leaves our rotation unsure about whether or not they will practice it. And that’s good. That’s what we need: a specialty of physicians who are really motivated, energized, overworked, ready to lead the charge for the next generation.
What do you think are the most pressing issues facing Emergency Medicine today?
I think the issues for Emergency Medicine are similar the issues that others feel broadly. One is fundamentally around the organization and delivery of services. We feel I think, in the policy reimbursement side, this transition of how we deliver care in the emergency department from being episodic providers that are paid based on volume toward being providers that really start caring for populations of people and are paid very differently and think about our care very differently.
That goes hand-in-hand with the second thing that’s changing in Emergency Medicine, which is what it means to be an emergency physician. There’s recently a task force as part of those thinking about the future of Emergency Medicine, and the term that kept getting used was that we are not necessarily just emergency physicians, but in many ways we are availableists. That to be a great emergency physician is not just the ability to take care of heart attacks and strokes and trauma and sepsis, which is what brought many of us to this field, but it’s also the ability to be an acute diagnostician for anybody who has chest pain, a headache, or abdominal pain. It’s the ability to be the safety net provider for vulnerable populations that can’t access care elsewhere. It’s the ability to provide urgent care, observation care, telehealth. So I think what’s happening in Emergency Medicine is a real challenge when trying to think about what practice looks like ten years from now. It’s going to look very different than what practice looked like ten years ago. You put those two things together and throw the COVID pandemic on it and then you really see why these are issues. Now, the COVID pandemic in and of itself is not a threatening issue to Emergency Medicine in the sense that the specialty would disappear. But what it shows us is sort of how we need to think differently about the way we practice medicine, how we deliver access to acute unscheduled care, how we get paid in terms of delivering that care, and also what our role of the emergency department is in national preparedness and response. I think historically, the country has taken a EDS for granted. We’ve never really funded things like EMTALA or preparedness and response. And as a country, we’re going to have to rethink that now, because we now see what the front line is how important it is how much of a difference it made in our ability to respond to a pandemic. And so hopefully, we’ve kind of take the national actions to make that a reality.
Finally, is there a moment in your career as an emergency physician that stands out to you?
It’s a great question because there are many that really stand out to me. It’s what you remember looking back based on different things. One of the first cases I can remember that really sticks out to me is, as a second-year resident there was a family member of a patient in the ED who went out to get a bite to eat. He made it about 40 feet out from the emergency department, but far enough to get into a parking lot where there was nobody around, and he had a cardiac arrest. That the time was fortunate that one of our techs happened to be out there, saw it, quickly got help, and was able to rush the patient to the emergency department. I was part of that resuscitation. Ultimately, the patient survived and walked out of the hospital with a defibrillator a week later. Being at the front end of a life-changing, life-altering experience for somebody at a time in their family was really struggling; it always reminds me that even the most severe of illnesses like cardiac arrest, we can have tremendous impact.
The other story I just love telling was when I was at the hospital, I was in the coffee shop in the lobby, and a woman had come in to have her baby. It was she was a seventh child I think she was going to have, and she knew that when you come in to have a baby, they don’t let you eat anything. So she stopped her husband and said, “Let’s get a granola bar, and something to eat on the way up,” because she wanted to eat something real fast before they went up to labor and delivery. Well as luck would have it, she all of a sudden passed out in line at the coffee shop, and the baby started to come out. I learned what it meant to be an emergency physician right then because I ran over and we delivered that baby right there on the floor of the coffee shop. They called a hospital code, they brought a stretcher over, we rushed her to the emergency department to finish the rest of the delivery. All went well with the baby and the mom did great. I still remember that moment, because at the time, one of our hospital OB leaders was in the coffee shop at the same time, and was screaming call a, code call a code. We recognize that there’s something about Emergency Medicine that trains you to deal with the chaos, work in any environment, and act fast in a way that a patient needs you to act, that nothing else in medicine can prepare you for. I still wear that story as sort of a badge of pride for Emergency Medicine that we were the one who pulled off the delivery in front of the coffee shop.
That is a wonderful story. And it really does point to what an emergency physician does.
I think we develop so many great clinical reflexes. In Emergency Medicine, I tell the residents that you can learn the whole book, but what’s actually happening over the course of residency when you’re training and learning is that the book is becoming sort of that clinical reflex you’re developing a pattern in your brain. And the skill of Emergency Medicine is knowing how to use your fast brain to use those reflexes and take care of people efficiently. But then to also recognize when something is a little awry and doesn’t fit the pattern, and then use our smarts to figure out what’s going on in those situations.
So wonderfully put. Thank you so much for your time and for everything that you’ve told me.