Finding Your Calling After Leaving Emergency Medicine with Dr. Kai Romero

“No physician is thinking, ‘You know what I want to do less of? Interact with patients, think about their illness seriously, and come up with a good diagnosis and treatment to manage their problem.’ No one's trying to cut that down. Everyone's trying to get rid of all the other crap, but the core parts of providing patient care, everybody wants more of that, not less.”

Dr. Kai Romero is an emergency and palliative care physician who recently became the head of clinical success at Evidently, a cognitive AI platform powered by clinical data. Previously, Kai worked at By the Bay Health, where she began as a hospice physician before moving into a leadership role as chief medical officer.

In this episode of How I Doctor, Offcall co-founder Dr. Graham Walker talks with Kai about her journey from those adrenaline-fueled days in the ER to the compassionate and complex world of palliative care. Kai discusses why she made the jump, what the two specialties have in common, and why ER doctors’ “soft skills” help them thrive in jobs outside medicine. She also makes the case that doctors in leadership roles should keep seeing patients and shares thoughts on empathy, physician identity, and the doctor-patient relationship.

Here are three takeaways from an episode packed with thought-provoking insights:

1. Emergency medicine and palliative care have a lot of similarities.

“The creativity with which you have to do home-based hospice is not dissimilar from the emergency room, and the ability to sort through bullshit, I think, is pretty well-honed as an ER doctor.”

While an ER doctor sees more intense situations and suffering during a shift than a palliative physician does, the same types of emergencies come up. Hospice care is like emergency medicine without specialized equipment and IV medications, Kai says. It’s also where a lot o

f patient stories that begin in the ER continue, and Kai was looking for a way to be involved in the rest of those stories.

2. ER doctors might not realize how in demand their non-clinical skills are.

“All things that we develop — the ability to form relationships rapidly, to get people to follow you and your idea in a crisis, getting buy-in from your colleagues — these are all things that we do day-in and day-out in the ED … they're actually applicable to the way the entire world works.”

ER doctors tend to focus on their “hard” skills, like diagnosis. But they also have this other skillset, which is well recognized in other fields as being predictive of career success. TL;DR: A tech startup has plenty of reasons to hire an ER doctor.

3. Physicians in administrative roles shouldn’t give up clinical work.

“I have always continued to do clinical medicine throughout, and I will say that has been incredibly important to me, not just because it's part of my identity as a doctor, but also because I have never gotten better organizational insights than I have by just taking call, seeing patients, running an interdisciplinary team meeting, and hearing presentations.”

Kai has realized that she can impact more patients in a leadership role than she can as a full-time clinician. But she also believes it’s helpful for administrators to keep seeing patients in a limited capacity. At some organizations, physicians can move into roles that are 100% administrative. And in those cases, Kai recommends negotiating for clinical time, because “it’s a mistake to get too far from the work.”

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Transcript

Kai Romero:

And I think especially when it comes to physicians, no physician is thinking, "You know what I want to do less of, interact with patients, think about their illness seriously, and come up with a good diagnosis and treatment to manage their problem." No one's trying to cut that down. Everyone's trying to get rid of all the other crap, but the core parts of providing patient care, everybody wants more of that, not less.

Graham Walker:

Welcome to How I Doctor where we're bringing joy back to medicine. Today, I get to sit down with Dr. Kai Romero, an Emergency and Palliative Care physician and most recently, the head of clinical success at Evidently, a cognitive AI platform powered by clinical data. But before stepping into that role, Kai was the chief medical officer of By the Bay Health where she made the pivotal decision to stop practicing emergency medicine and move into hospice care and leadership. I've known Kai since she was just a wee resident, then as a colleague practicing emergency medicine together for many years. Kai is a thoughtful, warm, and honestly hilarious person, and I'm so fortunate to call her a friend. In this episode, we dive into her journey from the chaos of the ER to the complexities of healthcare leadership, why she made the leap, and how she's using her experience to drive meaningful change in patient care.

Welcome to the show, Dr. Kai Romero. Thanks for being here.

KR:

Thank you so much for that lovely welcome, Graham.

GW:

First tell us what made you choose to pursue palliative medicine after an emergency medicine residency?

KR:

I remember the kind of rush of adrenaline around running a successful code. You're doing all these incredible things. You see this team working together beautifully. Everyone is doing their job optimally, and you get ROSC, and I remember just feeling like this is incredible and then following up on those patients a couple days later and realizing how many of them died in the ICU, and feeling like what I thought was the pinnacle of my career or my professional development was in fact the beginning of their dying process, and wondering if there might be a different way to think about how that could go. But I think what it really came down to was feeling like the storyline and the outcome that I saw in the Emergency Department wasn't the end of their story, and wondering if there was a way to be involved in the rest of that story.

GW:

Initially, I thought you'd maybe talk about that as a failure, but it's not that it's a failure, it's that it's only part of the story and you wanted to go further and pursue the full story, not just the first chapter or the most exciting chapter maybe.

KR:

Yeah, and we all of course also know the code that doesn't result in ROSC. That's its own separate type of sadness and suffering for patient, family, and clinician. I think we really ignore the clinician's experience as a part of that, but I think the combination of wanting to expand that understanding of what a life might look like at the end, and also I think actually that clinician piece of it, recognizing that there was just an avalanche of suffering in emergency medicine. It is that you are seeing people in the worst days of their life. You're seeing them in so much pain. You're seeing them in so much denial about their ongoing chronic illnesses, substance use, et cetera. Residency for me did not involve a huge amount of acknowledging grief, processing grief, managing grief, and palliative care was a space that really did for its clinicians, even though truly what an ER doctor sees in a shift is more intense than many palliative clinicians will see. Right?

Differences and similarities between emergency medicine and hospice care

GW:

Yeah, it's interesting. Yeah. When you think about emergency medicine and palliative care, I know people probably think they're very different. When you go to those places in your brain, are those two separate parts of your brain or are there ways that they complement each other or that they actually have more connection than maybe I might assume as an ER doctor?

KR:

I always say that hospice is really like, it's like emergency medicine with no specialized equipment and no IV medications, but the same emergencies come up. If you have a big tumor that's resting next to your trachea and you have sudden airway obstruction from it, well, I am not going to intubate you, but I do have to rapidly manage your symptoms around that. So I actually think that there's quite a bit of overlap and the creativity with which you have to do home-based hospice is not dissimilar from the emergency room and the ability to sort through bullshit, I think is pretty well-honed as an ER doctor. You realize these are all things that we develop, the ability to form relationships rapidly, to get people to follow you and your idea in a crisis, getting buy-in from your colleagues, these are all things that we do day-in and day-out in the ED and I think we think of as not the essential parts of emergency medicine all the time.

GW:

Well, you're describing a lot of soft skills that I think in medicine we typically are not nearly as trained on, and we do not focus on. We focus on hard skills like procedures and diagnosis and gestalt and sick versus not sick.

KR:

When you think about, sometimes it feels like we're so in our own little silo that we don't recognize those skills. They're actually applicable to the way the entire world works. Why should you hire an ER doctor to work at a whatever tech startup? Well, because all of these things are actually applicable and true regardless of the kind of core clinical competencies, and I think outside of medicine, there's more of a recognition of the fact that these skills are predictive of being a successful professional.

GW:

You're absolutely right. I'd never thought of it that way, but a lot of it is triaging decisions, prioritizing, breaking complex topics down into manageable chunks that you can handle. It's a really good reason to maybe hire a physician or work with a physician. Kai, let me ask you for maybe our listeners that aren't as familiar with palliative care, were you born that you were just good at these conversations? Was it that Kai was nature versus nurture? Is this something that people can learn and get better at difficult conversations?

The importance of developing empathy through intentional effort

KR:

Yeah. Was I reading last rites to my teddy bears as a child? I think the combination of curiosity and not being super-worried about whether or not I'll be rejected for asking probing questions, I could have become a journalist I suppose, but I think it made me feel like patients actually are interested in answering some of the questions that I wanted to ask. And it wasn't in every field of medicine that you felt like the door was open to ask that question. You're not born with empathy. Children aren't born with empathy. Anybody that has kids can report back on this. I have a son who is 20 months old and he will literally try and push his eight and six-year-old siblings off my lap when I give them a hug. He's like, "Get out. That's mine."

But I think I've been delighted to discover all of the ways that I can expand that about myself with intentional effort. I think it's my life's work to figure out how do I show up meeting people where they are, no matter what that might look like physically, emotionally, spiritually, whatever. It's a challenging task, but it's very satisfying to discover a new way to do that.

GW:

When I'm away from the hospital, it's way easier for me to think of someone as a whole person and be like, "Oh, yeah, I want to be that doctor that thinks of the person as the full person," and then I get into the ER and it's just way harder, and it's also a fatigue thing-

KR:

Oh, yeah.

GW:

... It's way easier on the first patient of the day or the second or the third, is real hard the last patient of the end of the shift of being like, "Oh, this is a human. This is a person. This is not just their stack of diagnoses."

KR:

Oh, absolutely.

GW:

Kai, I want to transition a little bit to talking about your transition from emergency medicine to palliative care. I know that was a really big decision for you, but how many years into your emergency medicine career were you when you actually just started to even think about it?

KR:

So I continued doing emergency medicine through fellowship and then my first, when I finished fellowship initially what I was doing was two ED shifts a week and two hospice days. It was actually a really nice time. It felt like a really good balance of ED time and hospice time and time with my family. So it was really satisfying. But you do that stuff for a little while and people are like, "Why are you doing this part-time?" So I began taking on more and more clinical days at the hospice, which reduced me to once a week doing emergency medicine, and then I actually stayed in that steady state of doing five days a week of hospice work and doing emergency medicine once a week for, I want to say, six years. It was because I actually really clung very tightly to the identity of emergency medicine doctor.

It's still, if I could still say that about myself, I would because the type of person that an emergency medicine doctor is, it feels like my tribe in a really profound way. The humor, the pragmatism, the no-bullshit, all of it really feels very aligned, and I have just such good deep relationships with emergency medicine doctors. Really what happened was in January of 2022, I was considering getting pregnant with my third kid, and it was still during that time when you had to wear an N95 in the ED all the time, and I was like, "Do I really want to do what I've done for my last two pregnancies," which is wear an N95 for a whole shift, end the shift super-dehydrated and practically in A. Fib from not having taken care of myself? "Do I want to do that again?" And realizing, "No, I didn't want to do that again."

GW:

I do have to call out on that, practically in A. Fib is a level of severity of dehydration that I immediately understood, even though, I don't know that I've heard that before, but yeah, I totally get it. When you made that decision, what were some of the positives of, "Oh, okay, I'm full-time just in one role."

KR:

Yeah, there's practical stuff like being within one system, everyone kind of knows what you're doing. So no one's disappointed by your unavailability because they know precisely where you're supposed to be. I do think it allowed me to deepen some of my work on the hospice and palliative side.

Clinical care should still be part of leadership roles for physicians

GW:

You've transitioned to medical officer. What's changed now in that other transition for people that are maybe thinking about a leadership role?

KR:

One of the things that I discovered was that as a clinician, I had always understood that the maximal impact you have is on that specific patient that you're interacting with. And when I took a step back and got into this leadership role and realized that's true and if you develop a process to care for that patient well, you're not just impacting that one person, you're impacting many more. I have always continued to do clinical medicine throughout, and I will say that has been incredibly important to me, not just because it's part of my identity as a doctor, but also because I have never gotten better organizational insights than I have by just taking call, seeing patients, running an interdisciplinary team meeting and hearing presentations. You can hear about it from other people, but actually being in it makes such a difference.

I do think there are some organizations where they have a 100% administrative role for a physician, and I would say negotiate for some of that clinical time because I think it's a mistake to get too far from the work. To me, it always comes back to are you really hearing when someone is telling you something? Are you really listening to what they're saying? Because we're all theoretically listening and we're trying to-

GW:

Sorry, sorry, what?

KR:

... And then when the rubber meets the road, you're like, is it really that bad? Is it really? You start going down this rationalization pathway and when you yourself have to sit there and experience it, you're like, "Oh." Again, it comes back to can I extend this amount of curiosity, this amount of empathy to the people that are giving me this information?

GW:

I think that is such a key point and you're absolutely right. That is what I think healthcare workers hear when an administrator who doesn't walk the walk, doesn't talk the talk just says, "Do more." It's like, that's such a great way of putting it, "Oh, so you want me to just do a crapper job with everything else?"

Leaders figure out how to help doctors spend more time on patient care

KR:

And I think especially when it comes to physicians, no physician is thinking, "You know what I want to do less of? Interact with patients, think about their illness seriously, and come up with a good diagnosis and treatment to manage their problem." No one's trying to cut that down. Everyone's trying to get rid of all the other crap, but the core parts of providing patient care, everybody wants more of that, not less. And so I think your role as a leader is to figure out how do we get you more of that and to frame the understanding of how to optimize that in the form of, "Let me help you get there," as opposed to "Could you get off your butt and start doing something?"

GW:

Kai, I wish all healthcare administrators and chief medical officers would be as thoughtful and empathetic as you are. In our last few minutes, I've got some rapid fire questions. What's the number one thing you wish your patients knew about you personally, Dr. Kai Romero?

KR:

I wish they knew that I am one small part of a team that cares deeply about who they are, what their experience is, that's really working with them to get to wherever they want to go. I think often physicians are seen as this authority over a patient's body, over a patient's plan of care, and I wish patients knew that I'm just a well-informed consultant.

GW:

A guide. Yeah. Yeah, yeah. Kai, what are the best and worst parts of your specialty?

KR:

The best things are the ability to provide what I think is the type of care that most people want to provide, care that's aligned with who the patient is in their journey, healthcare and otherwise, care that gives them as many good days as they've got. The worst for me personally is that I do less diagnosis. I feel like I don't have that, I'm not working that muscle as much because if you have new pain in your back and you have cancer, it's probably a met, and I'm not going to do a lot more diagnosis than that. The worst broadly I would say is actually that within hospice care, there are charlatans and snake oil salesmen that take advantage of vulnerable people-

GW:

Oh, yeah.

KR:

... and we're always fighting to make sure that that's not the prevailing ethos, but it's more prevalent than I think any of us want to acknowledge.

GW:

Kai, if you could send one message to yourself on the first day of residency, what do you think you would tell that young whippersnapper?

KR:

I think I would tell her that emergency medicine is an amazing specialty that she should absolutely pursue, to look really closely at the people around me and how they are navigating their careers and their personal lives. I probably could have learned a lot about sustainability in emergency medicine from my attendings and mentors, but I just didn't ask.

GW:

Kai, what's the best financial advice you've ever received?

KR:

Always have a second mechanism for making money, to not rely exclusively on your primary job for financial stability because that can change. That feels like advice of a terrified millennial generation.

GW:

Yeah, that sounds about right.

KR:

Always have a side hustle, but it brings me tremendous relief to know that if one thing weren't to pan out, that I do have a backup that could float me.

The doctor-patient relationship doesn’t stop when aggressive care does

GW:

Kai, what's one medical myth you wish would disappear forever?

KR:

That stopping aggressive care is stopping care. And I think also this notion that physicians are only useful as long as they're providing interventions. That relationship is key and essential and important to a patient for as long as they have it. And so this notion that, "Well, okay, once the cardiology team can't cath the patient, we're signing off. We're removing ourselves because we are no longer useful." And its like did that relationship mean nothing. So I think the recognition that relationships matter and they matter deeply to patients, recognizing that that relationship can and should outlast your ability to provide an intervention.

GW:

Kai, thank you so much for your time and answers to all of our questions. Thanks for joining me today.

For interviews with physicians creating meaningful change, check out offcall.com/podcast. You can find How I Doctor on Apple, Spotify, or wherever you listen to podcasts. We'll have new episodes weekly. This has been and continues to be Dr. Graham Walker. Stay well, stay inspired and practice with purpose.