Dr. Matthew Strehlow: Hello everyone and welcome back to the Stanford Emergency Medicine Podcast. I'm your host, Dr. Matthew Strehlow, Executive Vice Chair of the Department of Emergency Medicine at Stanford.
Today, we explore what it takes to build a research career in emergency medicine from navigating the research pipeline to identifying where the future frontiers of scientific exploration are.
To help us make sense of it all I'm joined by Dr. Chris Bennett. He's an emergency physician, an assistant professor, and an NIH funded researcher. He also holds affiliations with the Stanford Institute for Human-Centered AI, the Center for AI in Medicine and Imaging, and the Center for Digital Health. Dr. Bennett, welcome and thank you for joining us.
Dr. Christopher Bennett: Thanks for having me,
Dr. Matthew Strehlow: So, is it okay if I call you Chris?
Dr. Christopher Bennett: By all means, please.
Dr. Matthew Strehlow: All right. Please feel free to call me Matt.
Let’s start by laying the landscape before we get into your story as an EM clinician scientist. I know you've done a lot of research on the state of the EM workforce. You are an expert and have written on the research pipeline within our specialty.
So, tell our audience a little bit about the state of the emergency medicine workforce.
Dr. Christopher Bennett: It depends on who you're asking. The emergency medicine workforce has changed over the last 10 to 15 years, and for the most part, there are just more emergency doctors. The caveat is that isn't necessarily a density that's felt in all locations equally. When you look in high metropolitan areas you see a density of physicians and that density is on the increase.
That's not necessarily the case in many rural portions of the country. Essentially, take a line from North Dakota down to Texas and you find large swaths of America where there are few, sometimes no emergency doctors practicing within these areas. And then when you take a closer look at these more rural areas, in some situations these are physicians practicing emergency medicine without having completed a residency training in emergency medicine and also not having board certification.
When we did our most recent analysis of the emergency physician workforce, we found that this population, those in rural areas were more likely near the retirement age. And one of the questions we're asking now is what's happened since COVID-19.
We know that within emergency medicine, doctors one to five years out of residency, and those towards the end leave the workforce much more rapidly and at a higher rate compared to those that have been around for a little bit of time.
But some of the concerns are we having is that this attrition amongst those fresh out of residency is increasing. And that's important for a couple of reasons. The first is if you leave the workforce early on, you aren't sticking around. And so, there's lost productivity and lost access to care for many people who more than ever need emergency doctors to be there as a way in which care in this country is transitioning.
Dr. Matthew Strehlow: You know, you're a researcher, you're a clinician scientist at Stanford. what's been your path? How did you end up in this space?
Dr. Christopher Bennett: I always make the joke that I was a scientist long before I was ever a doctor. So, the story starts as an undergraduate. I was absolutely convinced I was going to be a PhD, and I did. I followed that pathway. After finishing my undergraduate degree, I interviewed and was accepted into a PhD program where I spent a couple of years of my life. Not so enthusiastic about it now looking back, but at the time I thought I was doing awesome stuff.
Until I realized it wasn't truthfully my calling and with some degree of difficulty, but with the strong support of my graduate advisor, I took a step back and asked what, what was it that I wanted out of my life and what was it that I wanted to leave behind me? I still enjoyed research. Fundamentally, the scientific method, hypothesis generation, looking at data was something that I really did not want to give up.
But the approach and the topic was one that I had not settled on. And so, in the process of going through maybe an early midlife crisis, I decided I would go to medical school. In my third year, I happened to work with someone by the name of Dr. Judith Tintinalli, who convinced me that the best and only job that I was fit for was to become an emergency doctor. And by extension, she made a very compelling case. The opportunity to work with anyone at any point, for any reason, at any time, to see anything and everything that walked into the door.
But also, to get the opportunity to be with people at the most vulnerable points of their life. To be the physician who was there to potentially save their life or to link them to care or to provide that diagnosis they'd not been able to get. But also, then, to understand that it was a resource limited environment that was still ripe for research questions.
A lot of what we do in our specialty is stuff that's been defined within the last five to 10 years. Despite having been around for only a short period of time, we have led some of the most pivotal changes in the house of medicine and that opportunity to make an impact on a specialty, but clinical medicine broadly was really too hard to pass on.
Dr. Matthew Strehlow: Well, you can count yourselves among many amazing clinicians that were inspired by Dr. Tintinalli. So that's a good story. So, you're here. You've got this person who's told you that you belong in emergency medicine, you believe it, you go to medical school. It's a long path though, right?
And funding is, decreased over time or at least it's fluctuated significantly over time. How did you decide then to say I am going to keep going down this path? What was that motivation? And then how did you decide okay, well I didn't love researching this, this is what I want to research.
How did you identify that area worth chasing?
Dr. Christopher Bennett: Oh man, it was happenstance. It was sort of like a, a classic Friday night shift where you fumble through eight or 10 different differentials until you find something you think best fits my path to medicine. Much like that my path through research has never been linear, and it's always been, you know, there's a question in front of me that I can't quite identify an answer to and it doesn't exist, or at least it's not readily accessible so I asked the question and I approached it from the scientific method.
I cannot put into words how truthfully humbling it is to be able to sit and talk with people from all walks of life at some of the most vulnerable points of their time.
There is, in my opinion, no parallel to what we do in the emergency department. I am very grateful for the opportunity to practice medicine and to care for people who are who walking in the front door with anything, any reason, any time. Having said that though, the, the parallel is it's just so fascinating and so rewarding as well Then to ask bigger picture questions that have the potential, not just to impact the person in front of you, but the populations that they're representative of.
And over time the questions have changed. We've asked questions of social epidemiology; we've asked questions of social and structural terms of health. We've recently transitioned more to focus on transmissible infectious diseases, but the concept, the core concept is still the same. We want to understand how people who show up to our emergency department get care, the reasons why they don't, the reasons why we don't offer it.
And then the cost associated with it, with the understanding is in the next 1, 5, 10 years, a bulk, if not all, or the majority of care in the country is going to be provided in the ED setting. And we realized that the system is failing and it is increasingly relying upon us in the emergency department to answer big picture questions and.
With that in mind, it's a task. It's an obligation for us to make sure that what we do is good steward of financial dollars, good steward of the resources, the finite resources that we have, but fundamentally also making sure that the people get the care they need when they need it. And then being a part of that process is, again, kind of an awesome experience.
Dr. Matthew Strehlow: I had a conversation this morning with a couple of departments whose PhD candidates are really struggling. They are saying, well, I don't know, I'm going into this and maybe it's a funding desert or something like that. And they don't have a longitudinal perspective. And I would say that even right now, it's, it's a different environment than probably any of us have lived through. Do you have any advice or tips for people as they think about how do I maintain funding and support for the work that, that they want to do and that they believe is important?
Dr. Christopher Bennett: Yeah. And this is hard, right? So, much like everyone else around us is living in the same situation with the understanding is the environment is very difficult to be a researcher and understandably so, right? You have to do things that are interesting to you that make you feel as if you're contributing something to society and are contributing things, the better good of the people you work with and the patients you serve.
And then answering important questions in science regardless of the discipline. But it's hard because this is an unprecedented time, and I don't think that there's a parallel in recent memory to explain that there is a good answer that's going to sit well with everyone. The, the ivory tower, the lofty head in the sky, head in the clouds kind of situation answer is that, you know, do what your heart tells you to do. Answer the questions that you think are important. When you go to sleep at night, do you rest well? Knowing that you've had a day that's filled with making decisions or answering questions that are important.
But I don't know. I don't know the answer because it's difficult for all of us. We have had conversations with colleagues who have lost their funding, for which there's no return. And so, they make difficult decisions not only about their job, but the jobs, the people they support. And so, the thought process is, we take it one day at a time, one month, one election cycle at a time.
To understand that for the most part, public support and research continue to be quite strong. Across the country there is an understanding that the work that we do in medicine and in basic science continues to be important. The advances that we have in development of new drug, new technologies, changes to quality and centers of care.
They save people's life. And I think that memory isn't something that's too short such that it's to say that in four years, five years from now, that the situation might be a little bit different. And not to use the trite phrase of practice resilience, but maybe patients have nothing else.
Dr. Matthew Strehlow: Yeah. There was a comment this morning within that same group I was talking to where they thought that the lack of trust in the research the scientific method academia had already, hit bottom and it is now rising across not just the country but the world. And, and I'm hopeful for that and hopeful that your beautiful young kiddo will blossom into the scientists that you are 'cause I'm guessing they're going to have the brilliance that you do.
What about bridging these intersections? So, you're not just sitting in the emergency department focusing just on that. You have appointments with the human centered artificial intelligence and digital health and, and these things.
You're a bridge across many different groups. Tell us a little bit about how you create those bridges and how you foster them, the importance of them. And then maybe for people that are struggling to create those how can they navigate that?
Dr. Christopher Bennett: Yeah. I think the harder you try, the harder it is.
I think fundamentally when I think about what I do and the conversations I have, they all still are roughly the same in terms of the research questions that we ask. We want to know how do you get people to care they need, when they need it? Cognizant of the cost, cognizant of the finite, you know, limitations we have on resources.
And then when we hit a wall, we ask the question - if we can't answer this question, can other people do it? And again, with the understanding that artificial intelligence, digital health has been around for a while. But there has been this exponential growth in the availability of it, and the space is quite dense.
There are so many people doing awesome things that have the potential to break into medicine, to make the job that we do a little bit easier, make it such that I can be home in time to put my kid down for a nap or bed or dinner without having to spend six or seven hours doing administrative tasks or doing things that can be automated when I start my morning every day.
I have a process that I go through. We go through the Eisenhower Matrix, and I ask what I need to do, what I need to defer, what I need to delegate, and what I need to delete. And in some situations that delegate or defer is actually a conversation with people much smarter than I am and in different industries.
We have at Stanford this very unique perspective to be not at the cusp, but generally the bleeding edge of what's going on. The pulse on Silicon Valley's transformation of healthcare and these bridges are essentially conversations amongst people with a common core goal to make life better, to make care easier, to make care better use of resources to do things for people that were once considered impossible.
Not just a question of not if, but when the conversations are usually from the perspective that you have. I'm a doctor, I'm a geneticist, I'm a scientist. We do digital health-based work. The reality is I'm not a coder. I am not someone with an MBA. And so these conversations are finding people who want to ask the question that you want to ask, but offer perspectives that you don't have or can be synergistic in getting to the end result in a maybe a way that you would've done differently, but still the outcome still being the most appropriate path to it.
Dr. Matthew Strehlow: You mentioned Silicon Valley and being at Stanford and, and all of these ideas and inventions, but a lot of time I feel like there's these, inventions, but we're not really in the exact space we need to make something that's actually usable and functional.
And you've talked about the idea of being boringly usable. So, disruption that sticks, it's co-created and evidence-based and boringly usable. I just love that term, especially in a very high-paced, but what I consider a pragmatic environment in the emergency department. Tell us a little bit about that idea of boringly usable. How you, use that in your own day-to-day work, and then how you'd see others able to apply that.
Dr. Christopher Bennett: I fundamentally identify as a simple person. I have a routine that I like to stick to and deviations from it cause me stress and anxiety. Much like most middle-aged men of my, of my background, what I will say is the death of any great idea is in the scaling, the implementation certainly, but the scaling of it.
And for something to work, it has to work not under ideal conditions for which you have trained experts, but it's got to work at three o'clock in the morning when the only thing I've had to eat is a bag of Cheetos six hours ago. And I am seven cups of coffee into my shift. It has to work for people with minimal training.
It has to be facile to the sort of resource-limited environments that we work in. And it's got to withstand the real-world things of being tossed, being clean, being thrown around. And from technology's perspective, it also has to realize like, you can't have 35 clicks. You can't hide in the far corner of the screen.
It also has to be something that is facile and it is nimble to the real-world constraints of what we do. The best technologies are the things that you open, the box you put on the shelf and they work, or technologies that are seamlessly integrated into the background, or in some situations you don't necessarily know it's there.
There's this conversation of disruption and nudging and wedging, but fundamentally the boringly usable things are the things that we don't recognize that are there but make the biggest impacts.
And then I think in terms of disruption that sticks and co-creation is just the conversation that at the end of the day. One of the biggest parts of my research group is challenging the assumptions that we as scientists have about the types of care that we think should be provided. And I've talked about this extensively, but mostly to say, we have a hypothesis, we have notions about what we think is important to people.
When the reality is when you ask people what's important to them, we're usually wrong, and we're not wrong by a little bit, we're wrong by a lot. You have to co-create technology with the users, with the people who are going to be responsible for implementing. You have to co-create it with the people who are going to be the receiving of it.
It has to work; it has to have guardrails. It has to be sensitive, but it has to be pragmatic. And if you create it in a silo, it will not be implementable. It will not be something that scales and a great idea won't go anywhere.
Dr. Matthew Strehlow: A lot of folks, are struggling because of the many switches we have in our work, which is a, I'm a clinician one moment, I'm an educator, in another moment, I'm a clinician scientist or researcher the next moment. And I think that we talk about how all of that work builds up. What is your advice?
To people that are either feeling like a little overwhelmed from their clinical load or just from the, the very many activities that we have to do in our day-to-day work. What's your advice for how to manage all of that and avoid burnout?
Dr. Christopher Bennett: When you have the opportunity to find the perfect answer for that, please let me know. I feel like at the end of the day, someone who's, you know, I maybe am past the point of early career. I don't know, but I still ask that question on a daily basis. It's never something that's a static answer. I think my day to day to week to month to year looks different.
And so, the great thing about emergency medicine is I can stack my clinical shifts and then go back into the lab and sit on a thesis committee for one of the PhD students or graduate students that we work with. Or I can block my clinical schedule in a way that allows me to be on campus to teach lectures or to mentor early career scientists. And so, I think that flexibility is important with the understanding is you don't really task shift to any significant degree. And have good outcomes as much as compartmentalizing it.
But I also fundamentally think that with the advents of technology that makes everything accessible, sometimes learning to say no and when to say no and being okay, saying no is fundamentally ls one of the biggest predictors of success with regards to not becoming burned out. I think the reality is, it has to make sense to you.
Obviously, there are things that we have to say yes to. We are doctors who are asked to see very complex cases, and we do it because this is the job description that we signed up for, and it's a responsibility and obligation to the patients that we serve. And outside of clinical medicine, we sometimes have this perception that we can't say no to the things put in front of us because of the way in which our lives have been ingrained from the type A personality of medicine.
It's a hard conversation to have with yourself, but it's also a harder conversation to have with the people you love around you. You know, decisions aren't just me, they're with my family, they're with my staff, they're with my lab, and it has to make sense for the people that I work with.
I'm not a good person when I've ran 14 shifts in a row when I have two grants that are due and three papers. It's just the worst of me and understanding how best not to juggle, but to prepare for those outcomes and then saying, this is only this certain amount of time that I can work.
And having to sort of task shift. And in some situations, going back to the Eisenhower Matrix and deleting, if not deferring.
Dr. Matthew Strehlow: Deleting and deferring. I think that can be really hard for us. We've been trained to say yes, to try new things. We're emergency medicine. We like lots of things. We like lots of shiny objects.
But I do agree with you a hundred percent that you do have to say no. It's what you say no to as much as what you say yes to. And then I think it's also as you get a little bit further along. I think you can look back and say confidently that there are ways to say no graciously that don't close doors. And really practicing the art of the gracious no is an important skillset.
Dr. Christopher Bennett: Completely agree.
Dr. Matthew Strehlow: Almost every researcher has some kind of mystery that keeps them going, right? That keeps them up at night. What's the question currently keeping you up at night, that you're chasing?
Dr. Christopher Bennett: How can I make myself obsolete, or how can I make the demands on my time that are not key and important, not my problem. I think we as emergency doctors - and this is not necessarily unique to, to what I do or what my colleagues do as much as physicians in general - we do things that we feel compelled to do but don't need to do.
There are clicks, there are forms, there are documents. There are conversations that that we don't need to be a part of. And fundamentally, when Christopher was going into medicine not that long ago, it wasn't because of a desire not to be with the patient or not to be having conversations with those I'm caring for. I didn't want to go into this really administrative…or the paperwork or the documentation or the billing increase.
And I think in the background from our research, what we want to know is how can we provide evidence to people such that they make the best decisions possible without having to dig through landmines of information sensitive to the cost and the resources, but fundamentally like. How can we automate things that we don't need to worry about?
I mean, being a doctor is hard and it's getting harder, and it doesn't need to be that way. When I talked to one of my colleagues who was a physician in what they considered like the heyday of medicine, paternalism, certainly, definitely a different kind of medicine, but they sat with their patients, they talked to them, they were there with them, and they did an exam.
But it was one that was a part of the art of the practice, you know, the laying of hands, the healing of the patient with physical diagnostic procedures, but also the emotional connection that went with this long-lasting relationship. It was a different dynamic.
The way in which we practice medicine is very different today. There's so many things in front of us that we sometimes often, don't see the patient there with us. And I think that is for a lot of reasons, but it's something that has to change.
And if we can have a conversation with someone who maybe isn't a physician and nudge them in a way to make that easier.
And if we can, in the haystack of four or 5 million different technologies and these unicorns of startups, push it forward and like make our jobs easier, but still give patients care, and make myself obsolete - absolutely. Every single day I will go to sleep knowing that I put myself out of a job but fundamentally making the specialty better and making the care even better as well.
Dr. Matthew Strehlow: What does the clinician, scientist, researcher pipeline look like within the specialty?
Dr. Christopher Bennett: I think it's a pipeline for which we have a lot of promise and a lot of potential. But I think the big caveats to that is that when you look at federal rankings, whether it be NIH dollars, federal dollars, that non-NIH foundation, industry sponsored research, emergency physicians on average are less funded.
We are one of the least funded specialties, and that's with both regards to career development awards as well as large research projects. So, the S, the grants that all of us hope to get one day, and that's important because for many reasons people don't usually go straight to an R. They tend to have some degree of experience and success in career development boards, which dictate their familiarity with NIH process and then graduate on, and then by proxy start to mentor and supervise more early career scientists who do something similar.
When you don't have a lot of docs who've done well from K to R and don't have a lot of Rs, you don't have the institutional support and the memory to make it easier for people to fall on your tracks. And so, although there are an increasing number of people like me who have experienced NIH-funded research, that's not on average, this sort of expectation that emergency doctors across the country do this type of research or have career intentions for it.
A lot of people primarily practice research and parallel with their clinical environment, and as the expectations for clinical workloads increase, research is harder to do and in light of current changes in administration, the dollars are harder to get as well. And so, although optimistic, I think we have a couple of years in front of us before we can understand what recent changes to the how and who is funded, what that's going to look like for the future of our workforce with regards to physician scientists.
There's so many things I love about my job, but the opportunity to work with people like my graduate students, my postdocs, the fellows that I work with, the opportunity to see them learn something and see them ask a question and come to an answer and then have other people find value in it.
It's kind of an awesome thing there. And one of the reasons why I do the work that I do outside the department that I teach and I give these lectures and help policy and epidemiology is to try to show the value of what we do in the emergency department.
That's just beyond sewing up people or sticking needles in holes. Like fundamentally asking the questions that need to be asked that people don't want to ask for the populations that are underserved and under understanding, we're here, the front door is open, like we're going to keep talking, we're going to keep doing these things.
And eventually, you're going to start listening to us, but bringing other people into the good fight, you know?
Dr. Matthew Strehlow: Chris how has your work as an EM physician impacted your parenting?
Dr. Christopher Bennett: My child has, the most interesting number of sounds and responses to the most unusual things.
And there is this fear that goes into a new squeak, or a pip or a shake that is usually informed by a fear of like, is this a febrile seizure? Is this hypoglycemia and does the kid have hand, foot, mouth? And if anything, it is more terrifying to be a doctor and a parent than not. My husband, who is not a physician at all, has a healthy amount of fear, but it's one based on uncertainty. Whereas mine is sort of the, the worst-case scenario.
Fundamentally though it's with the understanding that it is for the most part, kids are pretty pliable. Kids are pretty resistant. I grew up in a very, very poor portion of the country and my first crib was a washing basket on top of the nightstand, so I made it through. My kid will make it through as well.
But fundamentally it's with the understanding that it's new, it's novel, much like being an early doctor, things get better with time, the more experience you have, and just knowing that with experience comes certainty and when certainty comes calm, she'll be fine. Much like going through the early stages of medical school and residency and fellowship and faculty position, like she'll be okay.
Dr. Matthew Strehlow: Well, that is amazing. And although she's scaring you, I'm sure she's going to be just fine, like you said, and equally inspiring as yourself.
That's a wrap for today's episode. Huge thanks to Dr. Bennett for sharing his experience and his expertise.
Clearly, we've only scratched the surface of the workforce issues and how to become a clinician scientist and, and the challenges with that pipeline. Keep tuning in for more on this topic in future episodes. For those listening, be sure to check out the show notes for link to Dr. Bennett's latest work and studies.
If you like today's episode, don't forget to subscribe, leave a review and share it with a colleague. And as always, we want to hear from you. Send us your questions, your ideas. And your feedback at the link in the description. Thanks for tuning in. We'll see you next time. Until then, keep taking care of anyone, anything at any time.
