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We sit down with Amol Shrikhande, a nephrologist, to explore the challenges faced by frontline health care workers in an overburdened system. We delve into the real-world impact of budget constraints, staffing shortages, and administrative decisions on patient care, as well as the emotional toll on nurses and physicians. Amol shares his insights on navigating the delicate balance between quality care and financial pressures, advocating for patient safety, and the silent struggles that many health care professionals endure daily.
Amol Shrikhande is a nephrologist.
He discusses the KevinMD article, “How one food truck saved a chaotic hospital shift.”
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Transcript
Kevin Pho: Welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Amol Shrikhande. He’s a nephrologist. Today’s KevinMD article is “How One Food Truck Saved a Chaotic Hospital Shift.” Amol, welcome to the show.
Amol Shrikhande: Thank you for having me. Appreciate it.
Kevin Pho: So let’s start by briefly sharing your story and journey.
Amol Shrikhande: Sounds good. I—well, I basically took the straight path in life, grew up in the Northeast. Undergrad at Washington University in St. Louis, med school at UConn. Did my internal medicine residency at Cornell, worked as a hospitalist for a year in New York City at Albert Einstein, then opted to do a subspecialty training at Yale in Connecticut for nephrology, and then found a job in upstate New York, Rochester. That was about 2010. I’ve been here ever since.
Kevin Pho: All right. So I’ve read somewhere about the declining popularity of nephrology as a specialty. So does that jive with what you’re hearing?
Amol Shrikhande: Yeah. All right. I would say absolutely, yeah. You know, where I work, there’s a small internal medicine residency program, and very few of the residents want to go into nephrology. And even a lot of the large academic centers are having trouble filling their nephrology spots. So it is a bit of a crisis, although thankfully, you know, mid-levels or APPs have helped out quite a bit. So it’s not like the whole ship is sinking, but it is not a popular choice at the moment.
Kevin Pho: And for those internal medicine residents or medical students who might be listening to you, what are some reasons why they should consider nephrology as a specialty?
Amol Shrikhande: I would say it is a very cerebral field. So if you’re a thinker, it’s a great, great specialty. And it really does allow you to have your hands in all different pots of medicine. Obviously, you’re going to have your outpatient clinic. You’re going to have your outpatient dialysis, but you also get to do hospital work, including ICU work. So it’s kind of a surprisingly diverse profession. And it’s, I guess you could call it internal medicine on steroids. If you really enjoy internal medicine and having your hand in a lot of different areas, it’s not a bad pick.
Kevin Pho: All right. Let’s talk about your KevinMD article, “How One Food Truck Saved a Chaotic Hospital Shift.” Tell us what led you to write this article in the first place, and then talk about the article itself.
Amol Shrikhande: So, basically, the article was trying to capture a little bit of a disconnect between what’s going on on the front lines in medicine and what’s going on with the administration. And so really, it was just about relaying my day-to-day life and experiences and trying to encapsulate what’s going on. And what’s interesting is I wrote it a bit as a sarcastic piece, to be like, things are not great on the front lines. However, in the minds of the administration, things are great. What’s interesting is some of the people who read the article actually found it to be uplifting, which is also great, stating that even though things are not great, people are trying to make things better. So, either interpretation is fine, but it was more trying to just capture where we are in modern-day health care.
Kevin Pho: And for those who didn’t read your story, tell us what it’s about.
Amol Shrikhande: Basically, it was talking about, again, day-to-day life in the dialysis unit with the typical stresses. And talking about how there’s never enough nurses and how there’s always— in order to compensate for that, there’s always pressure to cut patients’ treatment slightly short to accommodate all the patients who need a treatment. But obviously, that comes with side effects, which is what happened in the story that I wrote. And then I captured the stress that gets relayed onto the nurse, which then gets relayed onto the doctor. But I ended it by saying that, well, in the administration’s mind, everything is fine because they got a food truck in the parking lot. So that was the general idea.
Kevin Pho: So do you feel that disconnect between the front lines and administration is specific to a certain institution, or do you feel, talking with your colleagues across the nation, that this is an epidemic happening everywhere?
Amol Shrikhande: I think it’s the second thing you said. It seems to be an epidemic. Where again, frontline workers, nurses, other providers, are not feeling that they’re being heard at the administrative level. And to be perfectly fair, this is not to vilify anyone because I myself am not an administrator. I’m not a business person. So I know there are economic realities that need to be addressed. But I would say right now, this disconnect that I was trying to capture, I think it’s going on everywhere.
Kevin Pho: So now let’s drill down a little bit. What specific things do you feel that most administrators aren’t aware of? In your story, you mentioned things like staff cuts and not having enough staffing. So let’s drill down. What specific things do you want administrators to know that are obstacles to you providing optimal patient care?
Amol Shrikhande: Well, I think, so one basic thing is just ratios. Like, yes, a certain number of people can do a job, but can they do that job very well? You know, and that idea that, yes, the job is being done does not always equal the job being done well. So I think that’s a key concept. And then the other idea is that, yes, we all can work super hard for X amount of time, but then when we are like, am I going to have to do this forever? That’s when everyone all of a sudden starts looking for alternative life pathways. So that idea that quality of care matters. And yes, I admit as providers, we do whine, but happiness of providers is also very important.
Kevin Pho: So give us an example of how that focus on ratios and not necessarily the quality of the work—how has that perhaps been detrimental to patient care or made your job as a nephrologist harder?
Amol Shrikhande: Well, so for example, in a given day in the hospital, we have to dialyze a certain number of patients. And, you know, we as doctors, we know our nurses very well, we’re very friendly with them, and we look out for their well-being. But in order for them to accommodate all the patients, they often will ask, “Is it OK to cut this patient’s treatment? Is it OK?” And sometimes it is, but sometimes it is not, you know, and constantly having that pressure as a provider to not only have to take care of the patient but also take care of your nurses—that can occasionally be in conflict, and it’s just something that’s hard to navigate. So, you know, obviously in a perfect world, there would be enough nurses, and life would be easy.
Kevin Pho: You touched upon burnout earlier, about how workers can only work hard for a certain period of time, but if it’s persistently like that, they may look elsewhere. Are you finding that’s leading to turnover of staff? And if so, how does that turnover, again, affect patient care and affect what you do as a nephrologist?
Amol Shrikhande: Oh, yeah. I mean, I’m definitely seeing it on the nursing side. Again, the nurses will come in for three to five years, and then they’ll burn out and often just go into a different specialty. And then they get replaced with another nurse, but another nurse who’s not as experienced. And so that’s another—getting back to the administrative side, they might view a nurse as a nurse. But we know, as providers, that an experienced nurse is really something that should be prized. And I’m not sure that’s happening all the time. And then on a provider level, to bring it back to a personal level, I myself—granted, I always had this vision of maybe doing something else with my life—but I saw what was going on around me and I actually opted to switch to part-time in more recent years. Which allows me to have a healthier relationship with the profession and also pursue other interests.
Kevin Pho: And when it comes to training up a new nurse in dialysis, for instance, how long would it take for you to be comfortable with that nurse’s skills?
Amol Shrikhande: Obviously it varies, but I would say, I mean, a minimum of three months. But probably six. And sometimes up to a year because, you know, just like any specialty in medicine, there’s the book stuff, but then there are the real-life nuances. And it takes a little while. You know, I think those of us even in mid-career know that we still haven’t seen everything. So, you know, imagine someone three, six months in. So yeah, I would say if you have a really, really sharp person, three months, but it can take, you know, six months to a year.
Kevin Pho: So do you feel that administration—you implied this earlier—they’re not sensitive to those nuances? They just simply look at the numbers, they look at the number of bodies, and then they say the job’s done. Do you feel that there is a lack of sensitivity to the nuances that you’re talking about now?
Amol Shrikhande: I would say so. And again, again, I’m giving just my personal experience and my local example, and I know administration can be different in different places, but to answer your question bluntly, I would say yes. The feedback that comes from the front lines is not always valued. And that’s often done in the name of budget or budgetary constraints or, you know, other financial concerns.
Kevin Pho: Now, what are some ways you could suggest to bridge that divide? I know that others have suggested that administration sometimes go on rounds with the clinical staff to see what’s really going on on the front lines. And I know that’s happening in some places around the country. But if you were to run a medical institution, how would you bridge that divide between the clinical staff and administration?
Amol Shrikhande: I would say, A, what you said makes perfect sense. And then B, honestly, I think, at least on a local level, we have many administrators who have not truly worked in the sort of specialty that they’re administrating. So even some just didactic lectures may help, you know, like short 15-minute lectures. Like, this is dialysis. This is the reality of the world that we live in. These are patients; they have cardiac disease; fluid overload is bad—you know, these types of very basic things. But, you know, in a busy world, it’s possible that they’re lost on certain administrators, especially if they haven’t worked in this specialty.
Kevin Pho: So you’re saying that a lot of these administrators who are making decisions about staffing in the dialysis unit, they literally would have zero knowledge about the medical implications of some of their decisions.
Amol Shrikhande: I would say, sadly, that is occurring. Yes. Like I said, in their mind, a three-hour dialysis treatment—I’m giving the nephrology side, but three-hour dialysis is the same as a four-hour dialysis. And to be fair, sometimes that can be the case, but sometimes it can absolutely not be the case. And so then we’re left, as the provider, thinking that we’re the crazy ones. But, you know, I would like to think that’s not the case.
Kevin Pho: Now, what if we flip that scenario? Do you feel that more clinical staff should be involved in administration, perhaps to understand the genesis of where these economic decisions are coming from?
Amol Shrikhande: I think that would help. It would help on two levels. A, I think we would all just understand each other better, so it would lead to less animosity, if you will. And then, you know, certain clinicians may be more motivated, they may enjoy it, to do administrative work. And then getting those people with the experience in those positions could also help smooth that divide or bridge that gap.
Kevin Pho: And are you seeing that? Are you seeing examples of clinical staff being involved in administration to lend their medical expertise into some of these financial decisions?
Amol Shrikhande: Again, I think that’s different in different places. I would say in my local example, I would say, unfortunately, I do not see that happening. I think that would be very useful to the point. Sadly, I actually haven’t seen more staff just leave the hospital and/or switch careers rather than go the direction of administration. So again, this could be a local problem, but I’m just, again, giving my personal experience.
Kevin Pho: So just to be clear, rather than trying to change the system from within, you’re just seeing more clinical staff—whether it’s nurses, APPs, or physicians—they’re simply leaving for other environments.
Amol Shrikhande: Exactly. And whether that’s health care somewhere else in the country, another system in town, or just another life adventure, so to speak. Exactly.
Kevin Pho: And from what you’re hearing, is the grass greener on the other side, or are they, as far as you know, running into similar problems at different systems?
Amol Shrikhande: Yeah, I mean, again, my sample size on that is very small, so it’s very anecdotal. But I would say, unfortunately, it seems to be approximately the same, at least with the small number of people I’ve spoken to. Then again, sometimes change in and of itself is healthy. So at a minimum, they got the change, but on the back end, it ends up being somewhat similar.
Kevin Pho: And then when you express these clinical concerns to administration and supervisors, what normally happens next? Do they change anything? Do they listen to your concerns? What normally happens when you express some of your clinical concerns to them?
Amol Shrikhande: I think, again, I’m going to be fair here. I do think you have to pick and choose your battles. And if I really speak up and say, “This is not correct; this is detrimental to patient care,” I do believe I am heard. But in terms of the more systemic things, in terms of larger-picture agendas, like, you know, trying to get more nurses, et cetera, I feel like, unfortunately, that may fall on deaf ears. And again, I know there are budgetary constraints, but it’s sort of in one ear out the other. Or maybe the answer, unfortunately, sometimes is, “You maybe just need to stop whining and just do the work.” So there’s that sad reality.
Kevin Pho: We’re talking to Amol Shrikhande. He’s a nephrologist. Today’s KevinMD article is “How One Food Truck Saved a Chaotic Hospital Shift.” Amol, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.
Amol Shrikhande: Yeah, I think—thank you, I appreciate that. Actually, before I say that, I just want to thank you for creating this platform. You’ve been at this for like 20 years, correct?
Kevin Pho: That’s right.
Amol Shrikhande: So anyway, you should be proud of what you’ve accomplished. So I just wanted to sneak that in before I forget. But in terms of a take-home message, I think, really, at the end of the day, I still feel like the two most important entities in the health care system should be the patient and the provider. And I think, as providers, it’s our obligation to take care of those two entities, you know. And that may involve having uncomfortable discussions, putting ourselves or having some, you know, minor conflicts, et cetera. But I think if we don’t do that, if we don’t look out for patients and if we don’t look out for ourselves, I really don’t think anyone else will. And so it’s our obligation, and like I said, it’s OK to be uncomfortable sometimes if you think you’re doing the right thing.
Kevin Pho: Amol, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Amol Shrikhande: Thanks. I appreciate it. Have a good day.
