The Art of Communication in Neurology with Chris Cantrell

Episode Transcript
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Dr. Michael Kentris (00:02):
Hello and welcome back to the
Neurotransmitters, your podcastabout everything related to
clinical neurology.
Today I am joined by ChrisCantrell from the Cleveland
Clinic Lerner School of Medicine, a student there, I should say
I don't want to have any falseaccreditations, as it were.
What's the term?

(00:23):
We're looking for, stolen valorbut Chris and I met through
some mutual contacts at theAmerican Academy of Neurology
meeting this last spring andsome other mutual friends, and
he's got some interestingexperiences that I thought would
be potentially educational andbeneficial for you, our dear
listener, and today we aretalking about talking, or

(00:47):
communication as it would bemore properly understood.
So, chris, welcome to thepodcast.

Chris Cantrell (00:52):
Thanks for having me, dr Kentris, excited
to be here with you.

So I was very interested.
You know, anyone who knows meknows that I'm always interested
in the way that we communicatethings, and I think Shakespeare
probably said it best right,brevity is the soul of wit.
So, but in medicine perhaps,short is not always the sweetest
.
So tell me a little bit abouthow you came to be interested in

(01:19):
the art of communication in amedical setting, and kind of how
your school also fostered thatability to develop those skills.

Yeah, so I'm, like you were saying, still a
medical student, fifth year nowat CCLCM, planning on applying
into neurology, hence why I'm onthis kind of podcast topic, I
suppose.
But my interest in communicationreally came about as part of my
med school.
So there's a culture ofself-reflection that they try to

(01:51):
instill in their students fromreally early on.
It's taught, it's not justtalked about, it's really a
skill that's to be developed.
And so early on in my first andsecond year, kind of
experiencing that powerfulbenefit of strong communication
and teaching, and from mycolleagues as well, my fellow

(02:13):
students, and seeing how muchthat helped me to improve.
And then, on the other hand, asI aged in med school and
starting to teach some of theseyounger med students who are
just learning how to do thesethings, seeing how much it
helped them to try to use thosesame tactics and kind of evolve
and keep improving myself as ateacher, and seeing how much

(02:37):
they benefit from that and intheir own interactions with
patients as well, like comingback and telling me hey, I tried
this thing that we talked aboutand it seemed to work really
well.
So that's where I realized howimportant communication is as a
teacher, as a sort ofpractitioner of medicine at this
stage getting there, but itreally made me more interested

(03:01):
in it and to keep kind ofthinking about it as a core
principle of of medicine andjust being, I guess, a human.

Yeah, that that is one of the things that I
think gets neglected.
You know, all through I thinkthis is a universal experience
for everyone who goes throughmedical training is you're?
You're kind of the fly on thewall as a medical student and
you're watching a patientencounter a conversation with
the physician that you're kindof the fly on the wall as a
medical student and you'rewatching a patient encounter a
conversation with the physicianthat you're shadowing or

(03:29):
rotating with and you're justlike, ooh, this is really
awkward and painful to watch,and I think it speaks to what
you're saying, right, these softskills quote, unquote are
something like oh well, you know, you made it in med school.
You're at leastsemi-intelligent, so certainly

(03:49):
you can talk to another humanbeing in a rational and
reasonable way.
Not so much the case, right,this?
This is a skill that needsdeveloped and worked on, just
like any other kind of ability.

Yeah, so, um, early on in our med school they
get us started in acommunication skills course.
So there's two phases to this.
There's the first year courseand the second year course.
That first year course reallyfocuses on just the ground level
basics, fundamentals of how tointroduce yourself to patients,
how to set up what's going tohappen in the visit, how to

(04:23):
introduce yourself even just asa medical student, and to not be
shy about that or feel like, oh, I shouldn't be talking to you
because you're really here tosee the doctor.
The basics of the history howdo I do a social history?
How do I get an HBI?
Things like that.
How to deal with patients whomight be on the chatty side and

(04:44):
redirecting without being rude.
That's, that's one of myfavorites.
Uh, we, uh, one of ourstandardized patients, uh is, uh
, you know the, the archetype ofthe, the grandmother who wants
to give, give, give you cookiesand be like oh well, I'll bring
by, you know, cookies for you.
How do you redirect?
How do you redirect from that?

Um ask what kind of cookies?
That's the real question,exactly.

So all these kind of situations we throw
students into it's all in asmall group setting and you're
getting feedback constantly fromyour peers as well as faculty
preceptors and or a studentpreceptor which I was lucky
enough to serve in that rolelast year as a student preceptor
and then in your second year ofmed school they go on to kind

(05:29):
of more advanced skills whereyou get into more motivational
interviewing smoking cessationcounseling, delivering difficult
news, things like that whereit's you know you really don't
want to be learning how to do iton the job, things like that.

Where it's you know you really don't want
to be learning how to do it onthe job, absolutely Now.
Motivational interviewing issomething that we hear all the
time.
We're seeing it instituted in alot of you know, not just in
medicine but in a lot of theallied health specialties as
kind of a training curriculum.
But what do people mean whenthey say motivational
interviewing?

So for me, I think of motivational
interviewing as right.
So it's an interview, we'restill trying to get information,
but there is some kind of goalbehind the questions that we're
asking.
We do you're still taking yourcues from the patient, but
ultimately we're trying todirect them some towards some
sort of better health outcome,and I think the reason I like

(06:26):
the kind of motivationalinterviewing name for this skill
is that it really does comefrom the patient.
It's like to use the example ofsmoking cessation counseling.
It's evaluating how ready arethey to make changes, what stage
are they in, what would it taketo get to the next stage?
And uh, um, kind of taking thatlongitudinal approach of not

(06:48):
okay, I'm just going to tell youto, you know you need, you know
you need to stop smoking,versus what's it going to take,
uh, for for you as a patient touh be ready to make these, these
kind of lifestyle changes.

Gotcha.
So in my mind I almost envisionit like a form of kind of like
Socratic teaching, where you'reasking them questions like well,
do you want this thing?
Well, very often you know thatlike the medication adherence
whole conversation, which youknow is pretty universal but
yeah, it is kind of like well,we have these two choices in
front of us.
This one's most likely to kindof lead to outcome A versus
outcome B.
If you want this other outcome,then you kind of ask them to
analyze, like how are yourdecisions leading you towards or

(07:48):
away from what you actuallywant?

Does that sum it up accurately?
Yeah, no for sure.
And and I think that thatreally gets at the importance of
patient centered interviewingwe talk about that as part of
our, our training, uh, ourtraining in my med school and uh
, you know they, they are thecenter of everything.
You know they, we can't forcethem to do things that wouldn't
be particularly ethical, uh, orfeasible.

So, yeah, and I I almost kind of link it
in right, we tend to think ofthe phrase uh, for those who
work in medicine, our goals ofcare, right, Almost has like a,
a connotation that we're talkingabout end of life.
But that's not necessarily true, Right, Um, like I saw someone
just recently following up, uh,you know, had a, had a TIA, and

(08:32):
I was like we should probablyget some additional imaging to
kind of make sure that we aren'tmissing anything.
And he's like I don't want anyof that.
And I was like, well, you knowwhy not.
And he's like, you know, everytime, every time I have testing,
they put me in the hospital.
And it's like, well, sure, Ican understand that, Uh, but you
know he was very adamant, hedidn't want testing, et cetera,
et cetera.
Right, so those are his wishes.

(08:53):
He has, you know, capacity fordecision-making and so on and so
forth.
And so, while you may not agree, right, this is kind of going
back to our principles ofmedical ethics.
Like he has autonomy and hasthe, you know, the right to make
his own decisions.
And so it does become one ofthose things where you have
these conversations and you know, yes, you aren't going to

(09:16):
always agree with your patientsLike that is a hundred percent
going to happen, and I thinkit's it's a question of you know
, does this patient understand?
Have I communicated right?
To come back around to thetheme of the show, have I
communicated the information andthe consequences or potential
outcomes of these differentpaths in front of us?
Then that's really all you'redoing is providing advice, and

(09:45):
that's, I think, a lot of whereyou know a lot of physicians
that I see where they get reallyfrustrated with patients and
they make them sign out of thehospital against medical advice
and kind of these like semipunitive types of actions really
just comes from a lack ofcommunication about, about this.

Well then, that gets in the way, too of right
the the doctor patientrelationship, and how important,
how important that is to people.
Uh, you know, whether they wantto follow your advice or not,
if they don't like you, they'renot probably going to want to
listen to you as much, so that,uh, you know, stopping smoking
or taking that medication that'sgoing to keep them out of the
hospital.
They, they're going to view itcompletely differently if you're

(10:23):
, if you're not listening tothem.

And I know a conversation that I'll I'll
often have when I'm running inthe hospital is like I'll, I'll
be going in and see you know,like, uh, you know, Mr Doe, and
like, like, how's things going?
It's like I want to get out ofhere.
I'm like, well, you know, noone's keeping you go if you're

(10:45):
willing and we can kind of startoff a conversation.
But I'm always very upfront oflike I'm not keeping you here,
no one's holding you hereagainst your will.
Again, assuming they haveappropriate medical
decision-making capacity and allthat, and I think that,
depending on if you have yourkind of stereotypical, old,

(11:05):
curmudgeonly man, that helpsbreak the ice a little bit.

But you got to read the room I was referring to
the same guy and you know it'slike his wife's sitting there.

She drug him in here against his will.
That's the usual scenario,right?
But I think it's important tomake sure that you do educate
people about their options.
If they know that they canleave if they really don't want
to be here, that does, I think,at least subconsciously help

(11:36):
them buy in a little bit togetting what tests you recommend
and things of that nature, sothat you can move towards
hopefully mitigating those risksand providing them appropriate
medical treatment.
Again, that's my totallynon-evidence-based perspective,
just from clinical practice.

It's practical.
It's practical, but I agree, Ithink some patients have a sort
of they sort of perceive medicaladvice as coercion, depending
on how it might be, might beoffered, kind of like you're
saying, but really giving,giving them their options.
And then one thing I thinkabout with our old man drugged

(12:19):
in by his wife, as you weresaying, is knowing when, when to
pick your battles by his, hiswife, as you were saying.
Uh, is knowing when, when topick your battles.
I think that's kind of a trick,one of those nuanced aspects of
motivational interviewing of youdon't have to fix everything
all at once and say, okay, Iknow you don't want to do this
thing, but how about we do youknow this other thing that we
wanted to talk about?
Right, we'll get, we'll getback to the smoking next time,
right and we'll.

(12:40):
But let's take this medication,we'll see how goes.
And then let's revisit that atthe next visit, because not
everyone's going to be able tochange everything with just a
snap of their fingers, very true, or want to.
You know most people beingfairly resistant to change.
I think is, you know, a faircharacterization.
But yeah, no, I think justtaking things step by step is

(13:03):
really important.

Absolutely.
Now we talked aboutmotivational interviewing and
then, to be honest, that's theone I hear about the most.
But, uh, what kind of otherinterviewing styles are out
there?
Generally speaking, I don'tknow if they have as a as clear
cut of names or uh, disciplinesor anything behind them.

Yeah, and I'd say the one that we hear the
most about is probablymotivational interviewing.
Um, I think there's.
There's certainly other ways togo about it.
Um, I'm not really sure.
Like I said, I don't know thatthere are a lot of names aside,
assigned to them or at leasttaught.
Uh, in terms of you know, kindof what we went through, um, but
in terms of like talking topatients specifically right now,
there might be other ways of ofkind of what we went through,

(13:42):
but in terms of like talking topatients specifically right now,
there might be other ways ofkind of looking at interviewing
or, you know, if you even loopfeedback into the interview kind
of sphere.

Right, and yeah, that brings up a good
point.
We're talking mostly aboutpatient provider types of
communication and I think in thesecond half, patient provider
types of communication and Ithink in the the second half
we'll move into like peercommunication, which is also
very important, uh, given thatmedicine is very much a team
sport.
But um, before we move on tothat, one of the things and we

(14:16):
kind of danced around this alittle bit is that we'll very
often see patients fromdifferent backgrounds, whether
that's cultural, educational,different kinds of preconceived
notions and things of thatnature different intellectual
people, especially in neurology,people with different, maybe
intellectual disability.

(14:37):
So how do you go about, or whatkind of evidence do we have, to
suggest different forms ofcommunication in these settings,
or trying to connect with theappropriate level of information
, versus diluting our messagetoo much where the patient's not

(14:57):
actually receiving thatinformation in a meaningful
manner?
Mm-hmm.

Yeah.
So I think there's a number ofthings that can help there.
Uh, for me, I always, no matterwho it is, I lead, let the
patient lead to some extent.
Um, so that's where questionasking, uh, leading with what's
your understanding of yourcondition or what have other.
If you're in the hospital, youcome in, you've got a console,
what have the doctors told you,um, instead of just assuming

(15:25):
that they know thing, you know X, thing Y, thing Z about their
condition.
So I always start there.
That generally will also giveyou a pretty good baseline of a
how well they understand theircondition, be their level of
health literacy.
And then from that you know,because obviously you have to

(15:46):
make some kind of judgment callon how you're going to describe
what you need to, what you'regoing to say about their
condition, their medicationsthey need to take, treatment
planning and then teach back.
I think is also kind of ahelpful thing.
So after so, summary statementson your own part while you're
doing it and then saying at theend you know, can you explain to
me?
Kind of a helpful thing.
So after so, summary statementson your own part while you're
doing it and then saying at theend you know, can you explain to

(16:07):
me kind of what we just talkedabout, just to make sure we're
on the same page, or what's yourunderstanding of of kind of
where we're at now?
Uh, just to get that kind ofextra confirmation and to make
sure that they know it wellenough, uh, both to uh, uh to
understand what's going on andto communicate it to you know
their other, you know healthphysicians, if they bring it up,
or or anything like that.

Right, I can't tell you how many, how
many visits I've had in theoffice where someone comes in
and you know they unfortunatelytheir records are not not in the
office and they had their careat some outside system.
So they told me I had a stroke.
I'm like, oh, what happened?
I was like I don't know.
I was like, oh well, that'sgoing to be challenging.

(16:49):
So you end up having to reallydig for that collateral
information which I thinkneurology is kind of a unique
thing, because so many disordersaffect people's memories and
recollection of events.
They may have memory loss fromthat specific period of time, or
maybe they had a more long-termneurologic disability or

(17:11):
deficit from a stroke or someother kind of injury, and so
you're really leaning heavily onthat patient's caregiver
whether that's family, friends,what have you?
And those outside records fromwherever their care was given.
And that's very challenging andwe see it in the hospital as

(17:32):
well, when you know if theirfamily member is not there at
the bedside.
You got to track down a phonenumber.
Hope you get through, hope thatperson you get through to knew
the person well enough that theycan tell you about what was
going on beforehand.
And so there's all these likethings where you know you're
sometimes kind of operating in alittle bit of a fog of war,
where you don't really know allthe details that would really

(17:56):
inform your clinical decisionmaking.
Um, and it can be, it can bequite challenging.
I think neurology is somewhatunique.
Probably psychiatry also facesa lot of that sort of thing,
right, anything dealing with thebrain you kind of you know, to
borrow from literature you kindof have sometimes an unreliable
narrator, and that's especiallyearly on in my career.

(18:17):
I found that to be a verychallenging thing.
I remember, if I may, indulgingan anecdote.
Remember, if I may indulge inan anecdote.
I had this patient who came inand, uh, you know, she had had a
bilateral occipital lobe stroke, not a huge one, but uh, they
were present, right, and I goand assess her, you know, I'm
checking her visual fields.

(18:38):
All of a sudden she, you know,she's counting the fingers
appropriately, all this kind ofstuff, and I'm talking to my
stroke attending and he's like,like she could see, and I was
like, are you?
And I was like yeah, and he'slike, are you sure?
I was like I think so, andright, like with every question,
I begin to doubt myself alittle bit more.
And it's like, and he just sayswe'll see.
And so we go into the patient'sroom and he just asked her,

(19:01):
like what color is my shirt?
And she like bombs.
And she had just guessed likethe right number of fingers,
like three times in a row and Iwas just like, oh my gosh.
So I felt like a complete fool.

(19:27):
Question your own assumptions.
Um, if you think that the personis having impaired
communication, whether that'sthem taking in the information
or giving the information oftheir own history to you, and
that's something that, uh,whenever I'm like rushing in the
hospital or I'm not taking thetime that I should be, you get
burned on it.
It's, it is a perennial fact,and so it just, it reemphasizes,
right, like I remember when Iwas an intern doing my internal

(19:49):
medicine, we spent so much timelooking through records and labs
and you know all these CTs andwhatnot, and I find in the
practice of neurology that ratiois flipped and we spent, I
spend, you know, like an hourtalking to the patient and and
I'll spend, depending on theperson, 10, 15 minutes looking

(20:10):
at their records and images,depending on how much workup
they've had in the past.
A lot of times you find thatthe interviewing is where a lot
of your diagnosticdecision-making happens and a
lot of that explanation ofrecent events.
A lot of your your diagnosticdecision making happens and a
lot of that, uh, explanation ofrecent events.
And a lot of times, as theneurologist you're asking I a

(20:32):
lot of times I preface this whenI'm talking with patients like
I'm going to ask you somestrange questions now because,
like, especially for likeseizures and things like that.
Right, you're asking about allthese weird experiential type
things and they're like I meanif you're if you're hot on the
trail, right, you're askingabout all these weird
experiential type things andthey're like, I mean, if you're,
if you're hot on the trail,right, they're like, yeah, I am
having deja vu with like a weirdburning smell.
It's like that's so weird andit's like that happens right

(20:54):
before you lost consciousness.
I'm like yeah, I'm like okay,and it right, these are just
things that most of the time,people aren't aren't asking, and
I find that that's a verysatisfying part of the job is
when you can, kind of you, youstart asking these questions
when you have a clinicalsuspicion of some entity and,

(21:15):
yes, it's important fordiagnosis, but it also, I think,
provides a very strong rapportbuilding event with the patient
because like, oh, finally here'ssomeone who's asking me about
these things that I've beenexperiencing and is taking the
time to listen and not just, youknow, writing it off and saying
it's all in my head.
And you know a lot of thesekinds of stories that we hear,

(21:36):
especially from you know peoplewho are like younger women or
minorities or things like this,where they kind of get dismissed
a lot of times when you havethese strange neurologic
symptoms.
So I found that again right inmy own practice that this is one
of the more satisfying thingsis when you're able to provide

(21:57):
this answer to someone who'sbeen kind of looking for
something to explain thesestrange events in their life for
months, or sometimes yearsspeaking of uh, patients who are
misdiagnosed or not listened to.

Uh, a lot of my clinical work and research work
has been in pots posturalorthostatic tachycardia syndrome
and uh, a lot of young females,you know 20s, 30s have had
symptoms, you know, unexplainedsince teenage years.
Or you know, close onset aftera GI or viral respiratory

(22:33):
illness.
And you know a lot of them aretold because you know symptoms
being palpitations, syncope,loss of consciousness, very
heterogeneous.
You know gi stuff, uh, changesin sweating.
Just you know autonomicsymptoms.
The autonomic system iseverywhere.
So you get, you know, a wholelot of different signs and a lot
of them have migraines, ibs,you know sort of uh, those kind

(22:58):
of things.
So a lot of them are told it'sjust anxiety, you have an eating
disorder, even though they have, you know, poor gastric
emptying.
Uh, you know they, they get,they are, they feel not listened
to and by the time they get tous, even just uh, having someone
listen to what they're sayingand not just immediately tell
them oh, this is what it is, um,even that alone builds an

(23:20):
enormous amount of trust.
Um, which was surprising to meat first because I was like they
must really have felt, you know, not listened to or ignored or
dismissed, kind of like you weresaying.
To get to that level that evenjust being listened to and it's
not like we tell them, oh, wehave the fix, you're going to be
immediately better, right, youknow, this is one of those.

(23:43):
You know, can be kind ofchronic.
Uh, you know, it can be kind ofchronic.
It may get better, it may staythe same, it may get worse, um
and but having that kind ofanswer of, okay, we're going to,
we're going to test you, we'renot going to turn you away,
we're going to treat yousymptomatically, um, because
that's the best that we haveright now.
But, uh, and then you know,lifestyle management and patient

(24:04):
education.
We do online virtual sharedmedical appointments that people
can hop on, almost like a justkind of almost like a Zoom class
.
I guess you could say it wasjust like we're going to have a
topic of the day.
Talk about here's how you canexercise when you feel like you
can't get up during the day.
Here's how you can modify someof your diet.
Here's how you can, uh, youknow, modify some of your diet

(24:29):
and uh, even even that alonejust listening to people and
making them feel heard can havean incredible impact on their
health, right, yeah, right.

We always think about communication as us
talking, but sometimes it's justlistening and, uh, yeah, taking
that information in, and that'sthe thing that I always think
is the most I shouldn't say themost interesting.
But something that's veryinteresting is that, you know,
through the course of ourmedical training, right, we
learn all of these $5 words forall these different conditions

(24:57):
and so on and so forth.
We have the person sitting infront of us who has some sort of
experience, and that's thestrange thing about neurology
and one of the phrases I reallyliked from Dr Aaron Berkowitz's
I think it's the preface of histextbook.
He talks about the practice ofimaging negative neurology,

(25:18):
which I think is where the artof neurology really lives.
There's no specific test.
It's for us to recognize thepathology and the way the
systems are supposed to work andwhen there's a deviation that
could be causing these symptoms.
But it's taking the way thatthey describe their symptoms and
translating that into what weknow on kind of our more

(25:42):
reductive medical side of things, and be like, can I extrapolate
the way that they're describingthese things into something
that makes sense from like apattern, more systemic kind of
description and it's challenging, right, it takes time, and that
is the thing I think in modernhealthcare that we really lack

(26:04):
the most is the time to sit andtalk with these patients for a
long time, and a lot of thesepatients right, if they're going
to their 15-minute familydoctor appointment.
Have you ever had a POTSinterview that was less than
those 15 minutes or less?

They're scheduled for at least an hour
usually.

So, yeah, that's exactly what I'm saying.
Right, it's this information,right it's.
It's very, by its nature, it'skind of nebulous, there's a lot
of vagueness to it, and that'sright.
That's kind of the nature ofhow our body interprets some of
these symptoms, depending onwhere they are in the abdomen or
the chest or things like thatand they may not be like.
Oh yeah, you know, it hurtswhen I push on my shoulder,

(26:48):
right, that's, that's prettyeasy to to suss out, uh,
relatively speaking.
But but it becomes this thingwhere you, if you don't have the
time, you're not going to makethe diagnosis and you're not
going to be able to help yourpatient, and I think that's
that's just as frustrating forfor someone who cares about that

(27:09):
sort of thing, uh, but yeah, itis.
It is one of these things wheretaking, taking their
information and, like you said,I think one of those, those arts
of communication is like, howcan I ask the same question like
five different ways?
Communication is like how can Iask the same question like five
different ways?
Uh, in as much as like, if wethink of like, say, like chest

(27:30):
pain, like, like, as an example,right, I was with my, my mom,
uh, a year ago and she had a bitof a cardiac event.
And I was sitting with her, wewere, you know, she had uh been
in the icu, uh, you're doing allright, she's fine now,
thankfully.
But, uh, but the, theintensivist, came in and like,
oh, you have any chest pain or,uh, shortness of breath or blah,

(27:50):
you know the typical review ofsystems, type litany.
And then the, the icu fellowand the cardiology fellow and
the cardiologist and theendocrinologist, right, and so,
like like five, six people in arow ask my mom if she had chest
pain and then, like after thefifth person she turns and looks
at me, was like, what do theymean by chest pain?
And I was just like, oh, my god, um, so, so it's one of those

(28:16):
things, right, where we weassume that people know what we
mean, but in reality this is notalways true.
And she's, you know, she's aneducated lady, right, she's got
a master's degree.
Uh, she's a school teacher, youknow, she's, you know, high
functioning in the overallpopulation.
Bell curve, simple, like chestpain.

(28:41):
Then what, uh, what can weexpect for for someone who's,
you know, less educated or lessinvolved with the medical system
and all that kind of stuff, andso it really is one of those
things where, if the answersthis is one of those things I
always say when I have, like youknow, students or trainees with

(29:02):
me is like if it doesn't makesense, then something's wrong.
Either you're not getting theright information or your your
differential diagnosis ismissing something, and so you
usually have to go back, getmore history right, ask more
questions, and I find that'sreally you can't ever really go
wrong by asking more questions.

I found yeah, I think the more, the more
questions I ask, usually thebetter I feel I understand.
You know the person that I'mtalking to.
So that's that's always mydefault.
And yeah, just really gettingtheir perspective on the issue,
like you said, and then justdrawing from misunderstandings

(29:43):
like that, remembering I'vedefinitely had had that
situation where I ask aboutchest pain and they say, well,
not pain, really more of apressure.
And then I'm like, oh geez, howmany people have said no chest
pain, but felt a pressure, whichis, you know, treated not too
differently, as I understand,and it's right, you know, in
cardiology.
it's like okay, we got to lookat it yeah so, um, just asking
any chest pain or pressure orjust making little adaptations

(30:07):
like that as you pick up onthese things can only benefit
without really the cost ofincreased.
That's not that much time toadd a couple additional words
for something that may beunderstood by a lot of people.

Right, yeah , I find one of my I should say
one, a couple of my most usedquestions in the course of an
interview, when things aren'tstraightforward, clear cut, is
what do you mean by that andtell me more about that?
And I find that those usuallyopen the door to some more

(30:41):
information.
Right, and I'm not anopen-ended question purist by
any stretch of the imaginationthere's definitely times where I
just want you to say yes or noto certain things.
But when you're on the hunt forthe diagnosis, right, like when
you're in the land of strangethings and vague symptoms, you

(31:04):
definitely have to be a littlebit, you know, cast that wider
net.
And uh, I find that sometimes,you know, I don't know, maybe
it's just me, but like,sometimes, when I get a really
good answer, I get likegoosebumps, uh, it just really.
Uh, it's just like, oh, I'm hoton the trail and uh, I don't
know, that's, that's what keepsme coming back to work every day

(31:24):
, I suppose the goosebumpsmoment, uh, yeah, no one.

For me.
That that, um, your storyreminds me of is dizziness.
So many different things canpeople just describe as
dizziness, and so the way that,uh, that I was kind of
originally taught to and adaptedto, uh to someone would say, oh
yeah, I feel dizzy.
So asking well, what doesdizziness mean to you?

(31:49):
Or I'll use this for othersymptoms too of like, OK, well.
They'll say, well, I feel off.
Ok, well, what does off mean toyou?
Instead of saying, well, whatdoes that mean?
Or you know, it keeps it lessskeptical for me.
Or like, okay, well, you knowwhat does off mean.
It's more so.
Just, okay, what does this meanfor you?
Because a lot of people willwill, I think, hone in on these

(32:11):
certain words of like okay, well, I'm having an off day, or I'm
having uh you know a goofy dayor a wonky day, like the number
of times I've heard thosedifferent words.

Yeah, and then you find out, oh, I keep
bumping my right shoulder intothe door jam, or my right foot
keeps tripping on the stairs,right, it's something like my
leg's cramping over and overagain and I can't straighten it
out.
Oh well, that's not just off,is it?
Yeah, it definitely, it's allthat.
Again, this is one of mymentors from residency.

(32:44):
She would always say whatcompany does it keep?
Right, everything is contextualand any symptom in isolation
may not mean that much, but it'swhen you ask around the symptom
you know, and that's where themedical training comes in.
Right, it's like oh, someonesays dizzy, well, I got to think
about their hearing and theirswallowing and their
coordination and you know, maybethe strength in their legs or

(33:05):
their sensation in their legs,right, all these things that
could manifest as quote unquotedizziness, and you have to
assess all of these systems thatwe know play into balance and
walking and so on and so forth,right, so it goes from dizziness
to like now I'm investigating aperipheral neuropathy, right,
or maybe you know some sort ofvertigo or what have you.

(33:26):
So it it really does depend,right, uh, and it's.
It's one of those things whereyou, like you said you just, you
ask more about it.
You ask kind of around, like ifyou have your central chief
complaint at the center of thatbullseye, like what's the stuff
that are kind of you know in thenext circle out, and sometimes
that can point you in adifferent direction.

(33:46):
My analogy is breaking apart,but but, uh, but it really does
matter, uh, in terms of makingsure, right, I think we've all,
and I'm sure you know, I knowyou're early in your career
right now but we come in, wethink, oh, and this happened to
me just recently Like, oh, wecome in, we think oh, and this
happened to me just recentlyLike, oh, you know, young person
, new onset seizures, had theMRI, the EEG, everything came

(34:09):
back normal.
Um, second event.
So we, you know, started somemedication, blah, blah, blah,
came in and now we're seeinglike, oh, like more seizures,
totally took a turn out of leftfield there.

(34:32):
But it's one of those thingswhere, when things aren't
behaving like, you expect themto, knowing the natural history
of these different conditionsand again, talking with the
patient, at the beginning it'slike, hey, if you notice.
I think it is this condition.
If things worsen, if we startseeing some of these other
symptoms, that's going to bewrong and we have further

(34:55):
testing that we need to do.
So setting expectations I thinkthat's probably one of the
other things that are like, likeyou were saying earlier, right,
like this medication.
Right, blood pressure medicationprobably not going to make you
feel better, but hopefully itkeeps you from having a heart
attack or a stroke andunfortunately, right so in our
world, like multiple sclerosistype treatments.
They may not make you feelbetter per se, but hopefully

(35:16):
they keep you from havingrecurrent flares.
And setting those expectationsup I've had a number of patients
over the years that I've seenin the hospital for a flare and
it's like, why did you stoptaking your medications?
Like I just wasn't, you know,it wasn't making me feel any
better.
I'm like, yeah, it probablywon't.
Um, and so right, the, if youdon't tell the people who you're

(35:40):
prescribing a course oftreatment to what it's going to
do, then they're going to havefalse expectations and there'll
be less adherent with yourrecommendations and you kind of
get this breakdown of thetreatment, the treatment uh plan
for for these people and it canwind up causing further harm.

Yeah, uh, I absolutely agree with that.
I think even even most of us inmed school can relate to the uh
, the person who came in andwasn't taking their blood
pressure meds or um, whether ornot you know, and then in
investigating I think also thisis important Uh, if they say, oh
, I wasn't taking my bloodpressure meds, asking why and
delving into that because itcould be access issues, right,

(36:20):
and you know, that's one we seefrequently as well.

I see a lot of people it's like, oh, you
know, it's like, oh, thatmedication costs like $200 a
month.
I couldn't afford it, right,that's a terrible story to hear,
but it's not uncommon, and sois it the better medication.
It might be the bettermedication, but the best
medication is the one that thepatient can, can get and can,
can tolerate.

(36:44):
So, uh, kind of a joke that I.
I mean, maybe it's in poortaste, but, uh, you know, I, I
do have.
You know, we get a lot ofbreakthrough seizures, most
often from med compliance, andI'll be like it was, like, oh,
you know, it's like, well, itdoesn't work if, if you don't
take it, and you know, as yousaid, sometimes they have side

(37:04):
effects, sometimes they theydon't feel well on the
medication.
So then you do have to divedeeper into it and and ask them
like, well, sometimes you canchange the dose, you can change
the frequency, right, there's alot of different ways you can
kind of uh, uh, work aroundthose issues if you find out
what they are.
So it's not just enough to saylike, oh, they weren't taking
their medication, this patient'snot compliant, right?

(37:25):
Uh, it's the patient's fault.
Uh, it could very easily be thedoctor's fault if they weren't
addressing what concerns thepatient brought to them last
time around.
So it's definitely important togo to those root causes.

Yeah, for sure, and I think, especially with
some of our POTS patientsfiguring out their symptomatic
treatment, some people prefercertain side effects to others,
depending on what's moreimportant for them.
If something has GI sideeffects effects suddenly like,
okay, I can't deal with any ofthat, or my you know, my POTS GI
symptoms are really bad, um,then you just got to find

(38:01):
something else that that worksbetter for them.
So it's kind of that, and and Ithink that's also an
opportunity for rapport buildingin both listening and saying,
okay, I understand, this doesn'twork for you, let's find
something else that does.
If, if there's a good optionavailable, of course, um and uh,
you know, really just keepingthat teamwork mindset and and

(38:21):
setting up that expectation forthe patient of like, okay, my
doctor's working with me tofigure out what's going to be
the best overall kind ofcombination of side effect
inducing, uh, drugs that I'mgonna to to, you know, kind of
optimize quality of life whilealso treating my condition.

And that's, that's.
That's the other thing.
You know, it's kind offrustrating to hear about Um.
I think again, one of mymentors during training uh, the
practice of neurology ishumbling, right in his words,
because you're wrong so often.
But, um, and I found that to betrue, uh, unfortunately.

(38:59):
But one of the things, like youknow, a patient will come in
like oh, I'm, ever since Istarted, you know, whatever
medication, I've been havingthis side effect and I was like,
is that?
And they would ask like youknow, is it possible?
I'm like, and I was like, itusually doesn't do that, but you
know anything possible.
So you definitely have to right.
There's what we read in thepackage inserts for these

(39:20):
medications and what's reportedby the FDA and all that jazz.
But there's so many variablesthat we can't account for
realistically.
So it's always good to keep inmind.
You know, could this be a sideeffect?
Well, sometimes you gotta do alittle trial and error, uh, try
some things out and see, and ifthe set, you know symptom goes

(39:41):
away when they changemedications or come off,
something like, yeah, I guess itwas um.
So I've certainly, you know,seen some unusual side effects
to things that we kind of usepretty routinely in neurology
over the years that I was like Idid not expect that to be the
cause.
Um, like someone had like thesevere anemia from from

(40:03):
levotiracetam or kepra.
Uh, like we you know rarelywill see like some
thrombocytopenia from it uh,pretty uncommon.
But you know they took them offthe meds, blood count popped
right back up and you know can'texplain it, don't uh, don't
know why.
So it's one of those thingswhere it's like I really

(40:23):
wouldn't have expected that tobe the cause and it was.
So I think it's again tyingback to it listening, keeping an
open mind and being aware that,especially for some a lot of
neurologic conditions you know,pots being one of those there's
so many things that we don'tunderstand in terms of like
mechanism or cause or idealtreatments.

(40:44):
So it really does keep youhumble.
Uh, I will say yes.

Well, that's what I was saying, just like you
were.
You were mentioning beforeabout your mentor saying
neurology is humbling.
It certainly is, and, uh, Ithink we got to learn to, uh, to
not anchor too hard on what ouryou know, what our thoughts are
and and uh, uh, you knowsomething that that I often will
tell patients is is that theyknow their body best.

(41:10):
They may not know theircondition or how to treat it the
best, right, but they know whatthey're feeling, um and uh, as
long as you lead with that, nowI know there's, you know,
malingering and factitious, andyou know, sometimes things
happen those, those ways, butthat shouldn't be at the
forefront of your brain.
No, generally speaking, when,when dealing with, with patients
, of course, so giving them thatkind of validation of okay, I

(41:31):
hear you, and then you got totake their, their kind of world
of living with the condition inour world and trying to
understand it and treat it andfind the way to get the best.
That is much maligned in themedical community.

But if we're talking with our
colleagues or other medicalprofessionals, whether they're
more senior, more junior, solet's take your own experiences.

(42:02):
You know, going through thistraining program, right, you
were providing feedback to morejunior medical students as
they're going through thistraining program and you
yourself were on the receivingend of it previously.
So what, what does that looklike?
What are best practices?

Yeah, so it.
It even starts very right atthe beginning.
First year you're giving peerto peer feedback.
Same level, same class, yourbrand new friends.
You've got to tell them here'swhat I think you're doing
effectively and what I thinkthat you could do better.
And that in itself is a jarringopening to uh, to med school,
because you have to learn how tobalance.

(42:38):
I want to tell this person theydid great.
I want to give them somethingmaybe they can work on, but I
also don't want to hurt theirfeelings.

So this isn't like a Festivus airing of
grievances type situation.

Generally not.

Okay.

It is all on the record.
Their physician advisor isgoing to be able to see
everything.
So I think, at the beginning,people are generally very and
going into medicine generally,people who might be described as
perfectionists are striving forthe highest mark, because
that's what we had to do inorder to try to get here.

(43:13):
And all of a sudden, you knowour uh, the cleveland clinic
learner college of medicinedoesn't have grades.
We have feedback only, um, asis how we're graded, and um,
that that in itself is anadjustment to begin with, but
that's really how the real worldworks, right?
We don't, you know, spend ouryear working as a neurologist

(43:35):
and at the end be like, okay,you got an A this year, good job
.
Or you got a B, do better nextyear, right.
It's like, okay, here's whatyou did effectively and here's
what we can work on for nextyear, so that that in itself is
a, a transition, um within thepeer to peer format.
Um, I think we.
I think we improved both in thegiving and receiving of feedback

(43:56):
, which I think are two verydifferent things.
So, in the giving of feedback,picking actionable feedback,
that at that level, you don't gotoo crazy with it, right, you
just say you can work on yourtime management in your 15- 15
minute presentations or maybeyou can do better eye contact

(44:17):
next time, right?
Just the kind of soft feedbackthat you can, that you can
improve on but that you canreally show improvement in,
based on you know futurefeedback forms and that's kind
of a longitudinal structure ofyou're getting feedback from
your peers over, uh, like awhole whole.
You present that and you writeup a portfolio, as we call it,

(44:38):
sort of a long essay, using yourevidence that you've gotten
your feedback to prove that youboth are competent in what we're
supposed to be able to do interms of the med school
requirements and that we'veimproved.
So it's an improvement mindset.
And then when you get more intothe peer like older peer to

(45:00):
younger peer I think you seethat evolve in terms of.
So when I was working as a CScommunication skills preceptor,
I had the opportunity to give alot more feedback to younger
students and in that, havingbeen in their shoes recently, I
felt like I could give them moretargeted feedback towards like

(45:21):
here's what I wish I had knownthen.
Or here's something that I'vebeen doing that I wasn't doing
when I was at your stage, butthat really helped me take the
next step.
So I think it gets a little bitless like I'm worried about,
you know, hurting their feelingsor them not liking me as a
friend anymore, and a little bitmore like here's something that
can really help you, because ithelped me.
Like two years ago or one yearago I didn't really feel like a

(45:45):
power dynamic.
I guess, you know, authority isprobably not the right word, but
I felt like they would listenmore to what I was saying in
terms of advice for how tochange, as opposed to right.
I'm.
I'm in here with my, you know,my very good friend who I've
known for a couple of years now,and I've got to give them
feedback on their presentation.
It's like, you know, good jobMaybe, maybe maybe more eye

(46:07):
contact.
It's a little.
It's a little bit different atthat level.

Right, right.
So feedback, obviously youhaven't been in the position
where you're the attending orthe senior resident on service
providing feedback to trainees,so that does provide.
I would say that power dynamicdoes shift a little bit as you
move more into this.
For better or worse, it's theway, the way it's structured,
this hierarchical, uh kind ofsystem, and so you know, you do

(46:39):
try, it's one of those thingsand I find that I have to to
balance this myself.
Also, you know, because I haveto think of, like what, what are
the goals of this rotation?
Right, are usually, you know,spelled out by, like the acgme
or, you know, the medical school, for, you know, student
rotations and stuff like that.
Like what do they hope for themto gain in terms of skills and

(47:02):
experiences and so on?
And so it's particularlychallenging, I think, for for
medical students, right, becauseyou don't want to like write
some some kind kind of uh reviewthat could be considered as
like scathing or things likethat.
So I usually do try to do moreinformal, verbal feedback rather

(47:23):
than writing like a long thingLike, hey, you know, your, your
assessments were, were prettyweak, uh, despite our talking
about them, and you didn'treally, you know, flesh out your
thought process, blah, blah,blah.
Right, it's like these thingsthat that we kind of hope that
people are getting better atover the course of a few weeks.
Um, and you know you don't wantto just write the, the

(47:46):
ubiquitous uh.
Read more in terms of yourstudent feedback either, right?
So so, from your perspective onthe receiving end, uh, on
clinical rotations and thingslike that, what do you think has
been the most useful way ofgetting feedback, whether, like
in the moment, at the end of therotation, in your written um

(48:07):
written assessments or what haveyou?

yeah.
So I think there's um.
Know, I guess part of itdepends on how long your
rotation is.
So let's imagine we have a oneweek rotation, right, and then
we're you know, and then you'reattending changes every week or
whatever it is.
I found it most helpful to havekind of a midpoint verbal
feedback and so you can assessokay, how am I doing what,

(48:31):
what's working effectively, whatcould I work on in these last
couple days?
And then the endpoints.
So whenever that attending oryour senior resident or whoever
you're working most closely with, is switching off service,
saying okay, here's how we'vegrown since then, and kind of
just overarching feedback.
I think written feedback cancertainly be helpful.

(48:52):
It's easier to go back and lookat and review later on because
it's it's always there, um.
But for me it's those kind ofverbal, kind of candid, just
conversations about, okay, howdid things go?
Um, it can be more comfortable.
That way you have a chance torespond as well.
Written feedback is just kindof it.
They write it down and thenit's just out there.
You't have a chance really tosay, okay, well, this is what I

(49:14):
was trying to do or, in thissituation, here's, here's what I
was thinking, or just toacknowledge like, yeah, I think
I could do better on that and,and I think acknowledging that
you have room to grow is also astrength and uh reflects well on
you, um, as a as a lifelonglearner.
As people like to say yes, butyeah, I think for me it's been

(49:39):
the verbal feedback that's themost helpful and some of the
most memorable kind of formativeexperiences.

And I think it's important to emphasize.
You know there are somerotations where that will be
more structured, where theattending is kind of built into
the rotation almost.
But there are many rotationswhere you know the attending is
of built into the rotationalmost, but there are many
rotations where you know theattending is busy, maybe they're
understaffed.
You know, I'm sure that neverhappens in medicine anywhere,
but if it is entirely possiblethey will forget to give you

(50:06):
feedback.
So I think, as a student or atrainee, it is important to seek
that out as well.
If you really have a genuineinterest in improving yourself
and I would say, doublyimportant if, say, you know
you're applying to thatself-same specialty, you want to
try and get a letter ofrecommendation, you really need
to be kind of going after thatuh and being uh, what they might

(50:29):
call in the business worldmanaging up a little bit, little
bit in terms of like, hey, youknow, dr, so-and-so, I really
like your opinion on how I'mdoing on this rotation and what
I can do to really, you know,perform well by the end of this
rotation, because I'm thinkingof applying to the specialty and
you know so on.
But it is, it is important toset those expectations early in

(50:51):
the rotation, because if youwant a letter of recommendation,
you're only with this personfor one week and they didn't see
you that much and yourperformance was a little
mediocre.
They're not going to write youa great letter of recommendation
, that's for sure.
And so you definitely need tomake sure that you're doing what
you can to put your best footforward.

(51:12):
You're doing what you can toput your best foot forward and
again right Kind of comes tothat communication aspect of
things where you're telling themlike hey, I'm interested, I
want to apply to this and Iwould like to do well enough on
this rotation to get a letter ofrecommendation from you.
So what do I need to do to dothat?
And then, executing on thatmidpoint, find out like am I, am

(51:34):
I heading in the rightdirection?
And hopefully, by the end ofthat period together, you've
done well enough that you've,you know, demonstrated, you know
improvement, or you knowwhether or not you're like.
There's always likesubspecialties where it's going
to be really hard to like, belike really impressive.
But it's the expectation ofwhat do I expect from a third
year or a fourth year medicalstudent versus what do I expect

(51:54):
from a third or a fourth yearresident, right?
It's entirely different skillsets, so.
So I think it's reallyimportant because I'll I'll
sometimes get requests for likeletters of recommendation, like
near the end of the rotation.
I'm just like you know I canwrite one, but you know it's not
going to be great and I hatesaying that, but it's, it's the

(52:17):
truth, right?
Um, yeah, so so it's.
It is important to make surethat you're like really
excelling, right, you want those, especially with residency
applications being the way theyare these days.
Um, you want to do everythingyou can to like get a really
stellar letter, and just havingthose conversations, I think is

(52:37):
a big.
It will dramatically increaseyour chances.
As far as, as that piece ofthings go, I don't know what's
your better, your experience assomeone more recent, uh, as
someone who went through ais inthe last three months uh, yes,
months, yes, very recent takes.

I, yeah, it's it , it is.
It is hard to open thoseconversations at times.
It's easier with the residents,especially those that you're
working closely with.
I would often seek feedbackfrom them, kind of at midpoint,
and, uh, you know the uh.
My favorite question is isthere anything I can do to be
helpful right now?
Um, just throwing those thingsout there into the wind to be

(53:14):
like I'm looking for ways to behelpful and then, when getting
feedback, making it a priorityto whatever that thing is of.
I want to see you work on yourdifferential diagnosis.
I want to see you going tocheck on your patients by
yourself in the afternoon andjust giving them updates,
whatever it is.
Patience by yourself in theafternoon and just giving them

(53:35):
updates, whatever it is.
Doing those things is going tomake you look the most
impressive.
Beyond just starting good andending good because it's like,
okay, this person wants toimprove, and someone who wants
to improve is someone who'sgoing to work hard, who's going
to be a good team player.
I think that reflects evenstronger than just being good
alone for me personally, as aperson who is constantly trying
to improve because there's roomto um and when with the

(54:00):
attending.
Sometimes it's hard, sometimesyou don't see them very much.
They pop in for rounds.
You walk around as a large team, um, and, and that's just the
way it is, because they'reinsanely busy and they've got a
team of, you know, eightresidents and one medical
student and they're trying totalk to everybody, right, um.
So it can be hard.
But catching those momentswhere it's like, okay, now is my
time, like it.

(54:21):
Just it hits in your brain oflike, okay, I've got a chance
here.
Just asking do you have anyfeedback?
And from what I've heard fromyou know attendings that I'm
close, they love hearing, that,they love giving feedback, they
love people who want to getbetter and, uh, um and to to
kind of help in that process.
And it doesn't even have to bea long conversation.
You just edit or two and thatcan make a big difference.

Right, and I do think again, right, this is
, this is my perspective.
You know I'm not currently at aneurology training program, but
when we would have medicalstudents who were there on a
sub-I rotation or auditionrotation or even just third
years who were interested inneurology or considering it,

(55:07):
it's like you get brought intothe inner fold almost
immediately.
So it's a double-edged sword.
Right, you will get theattention if they know that
you're interested in neurology,but the expectations go up
immediately.
So they're going to expect youto be doing a lot more.
But you will get that attentionand that personalized touch if

(55:31):
you're able to kind of meetthose expectations.
I kind of think of it.
It's like you know, joining acult, right, it's like, hey, I'm
interested in joining your cult.
Like, oh, really, let me tellyou about, about the good news
yes, yes, uh.
So here's what you have to do.
Here's your, here's your hammerand here's your tuning fork.
So, so, uh, but it it really istrue, like you know, if I I've

(55:55):
worked with a number of medicalstudents, even where I am now,
and as soon as they say they'reinterested in neurology, I'm
like, all right, let's, let'stalk about that.
And, uh, what we need to do to,you know, get your best foot
forward and get all those thingskind of lined up over the next
year and kind of right, it's asmall, it's a small community.
You know putting you in touchwith, with people at local

(56:15):
institutions and you knowgetting all those things moving
that are going to give them thebest chance to to get into a
program if they want to.
And I don't know, has that beenyour experience as well?
Like when you've expressed thatyou were like, oh, I'm
interested in applying toneurology.

(56:38):
Yeah, I think you definitely getmore uh direct attention, as
opposed to my surgery rotation,where I said I was interested in
neurology and the oppositehappened, which is right you
like fade into the wallpaperwhich you know I didn't mind too
much but no, it was.

It was good.
There was a lot of no.
I learned a lot through throughthat rotation as well.
But the uh, I'd say, on myneurology rotations you could
definitely see the expectationsgo up, but not in terms of
necessarily of being correct allthe time, which I think is a
common, just sort of instinctualassumption that medical

(57:06):
students or people who are beingevaluated, yeah, think that
they have to be right all thetime, and it's depressing when
you're not and, uh, I think it'shard to get away from that.
But having you know it's, it'smore about showing the that you
want to learn, that you want tobe part of that kind of team
that you're comfortable workingwith, kind of the elements of

(57:27):
that specialty and then yourpatient care and how, how much
your patients respond to you and, like you within the, you know
the confines of theirpersonality and you know and and
and all that.
But that that's what stuck outto me the most.
But it wasn't when expectationswent up.
It wasn't expectations that Iknow everything, it was that

(57:49):
expectations that I would wantto learn things, that somebody
on that rotation who wasn'tinterested in neurology would
not be interested in.

Right, and that's you know.
Same.
Similarly, from from theattending to the trainee side of
things, it is important to setthose expectations Like what do
I expect for for a third yearstudent, for a fourth year
student, for someone on a sub I?
For a junior resident, a seniorresident student, for someone
on a sub-I?
For a junior resident, a seniorresident, right?
These are all different skillsets that people should have
mastered as they go up theladder and saying like, or I

(58:19):
should say, for rotatingresidents, right?
So for people who are comingfrom internal medicine or family
medicine or emergency medicineonto the neurology service, the
expectations are different.
They'll have different skillsets that they're bringing to
the table.
A lot of times I say and this isright, if you already knew
everything that you needed toknow to practice neurology, well

(58:39):
, there wouldn't be much pointin the training, would there?
And I think, right to yourpoint, reassuring people that
this is in fact the case.
What do I expect?
I expect you to be able to talkto the patient, gather a story,
put the story together in acomprehensive and coherent way
and then create a differentialdiagnosis, right?
I don't know that you need tohave the correct diagnosis you

(59:03):
want.
There's a lot of weird stuff inneurology, you know.
Sometimes I got to do somereading too.
But the point is like, hey,let's engage in the thinking
exercises that go along with thepractice of neurology.
Right, the localization and thetimeline and kind of putting
together an appropriate list ofpossibilities and engaging in
that thought exercise more thananything, right, I just want to

(59:25):
know can you think that's reallywhat I want to see, right?
Can you talk to the patient,get the information and think
about it, and think about thingsthat make sense?
Not everything is a stroke, noteverything is a seizure.
There's other stuff out there.
Let's think about that.
So I think that's the mostuseful part of neurology.

(59:47):
I'm probably painting with toobroad of a brush, but I think
that gets lost a lot in otherspecialties, but in neurology
we're so dependent on it, thatinformation, that we can't.
Even if we wanted to, wecouldn't get away from it
because we would just be bad atour jobs.

Chris Cantrell (01:00:08):
Yeah, I think that's totally true.
And in terms of when you evolvefrom that year three, like, oh,
I'm interested in neurology,let's see if you can think like
a neurologist.
You go on to the AI.
It's like, okay, can you worklike a neurologist and do you
want to right?
Like, will you put in theteamwork?
Will you work?
You know, improve documentation?
Will you, you know, take careof your patients and you know,

(01:00:31):
review their charts and catch,okay, maybe we should have them
on this medication or that.
Um, you know, and all thosethings don't necessarily have to
happen, but are you looking forit?
And then you know, is, are youat that level of, okay, this
person could be an intern in ourinstitution and and be
successful?

Dr. Michael Kentris (01:00:48):
Right, and.
And so since you said the magicwords, uh, there is a great
book out there called how toThink Like a Neurologist that I
do recommend.
I actually interviewed theauthor on a past it's almost
been two years ago, I think nowDr Ethan Meltzer, but very good
book and it's just exactly whatit says on the tin.

(01:01:08):
So you kind of walk through andeach one is a little case and
they're like let's think aboutthis what's the localization,
what's the time course, what'sthe syndrome, et cetera, et
cetera.
And it's exactly that Like howdo we, you know, train our minds
to think like a classicalneurologist, different than how

(01:01:33):
an internist usually approachesa neurologic problem, or an
emergency physician or a familyphysician?
And I think it's good to havethis different way of thinking,
because the way that we tend tocreate our differential
diagnoses is, I think, a littleunique as far as that goes.
But just because the nervoussystem is what it is right.
But I think it's a veryinteresting thought experiment

(01:02:01):
to engage in and when you'refirst starting out like I wish I
had had that book when I was ajunior resident, it was very
helpful and something that Ijust kind of had to build over
time, through trial and error,but it's really, I think, helped
me at my stage of the career interms of crystallizing how I
right again we're talking aboutcommunication for those who
forgot as we were rambling, butthe kind of the transmission of

(01:02:23):
information.
So for me as an instructor to mystudents, like, why do I think
this?
You know, it's not just likegestalt, I mean sometimes it is,
but we need to try and putthose gestalts into words and
have reasoning and a rationalebehind what we do.
And I mean it's too often thatwe'll see like, oh, why did they

(01:02:47):
put you on this medication?
Why did they do X, y or Z?
It's like, oh, that's just Idon't know, that's just what
they did.
And you don't find anything inthe documentation, you don't
find any reason for something.
And it I'm always torn betweenmy twin desires like I shouldn't
say desires, but my twinthoughts of like there must be a

(01:03:08):
reason for why this person didthis, versus that seems like a
really stupid thing to have done, right.
So I just kind of ping pongback and forth and I'm just,
like you, kind of have to remindyourself like these are also
medical professionals.
There may have been a piece ofinformation that I don't have
that justifies what they weredoing at that time.

(01:03:28):
Right, yeah, um, so it's.
It's always easy to take theeasy way out and say like that's
dumb, they shouldn't have donethat right.
But in reality there may havebeen a reason, I just don't know
it, and so that's always thehard part.
So I think also to kind of tiein our third piece of
communication is like themedical record itself and these

(01:03:50):
paper charts, and notnecessarily the focus of our
conversation today.
But I think charting issomewhat important, although we
all hate it because of theburden that insurance has put on
us.
But I think it's important todocument what you're thinking
and why you're thinking it andwhat you intend to do about it.

(01:04:11):
Everything else is windowdressing, more or less, but if
you can at least document that.
So someone picks up your noteslike, oh, you know, dr Cantrell,
he thinks this person has youknow whatever, you know
migraines and they're tryingthis medication and they're
going to see him back in twomonths and see if it's working
or not.
And it's like, oh, I knoweverything I need to know about

(01:04:34):
this particular problem thatthey're dealing with and that's
really kind of important right.
It's like if we just do kind ofshoddy notes and they don't
explain our thought process,there will be a doctor who comes
along and says like oh, thatguy, he doesn't know what the
heck he's talking about, he'sjust, you know, he's just

(01:04:58):
throwing darts at the wall andso you don't want to be that
doctor, or at the very least youshouldn't be perceived as that
doctor because of poordocumentation.
You should at the very leastsay like why you're doing
something and what you think itis.
It doesn't necessarily need tobe, you know, a three-page essay
, although certainly in yourclinical experience, those POTS
patients, sometimes thehistories are quite extensive.

They can be.
They've been through a lot.

Yes, right, especially if you're working in
an autonomics referral center.
That's not the first port ofcall for many of these people.
There's been a lot of inkspilled previous to them getting
to you.

Yes.

But yeah, so that's kind of my perspective
, but it's that third way ofcommunicating.
Very often we're communicatingasynchronously and remotely to
our other colleagues.
Medicine is so fragmented thatwe may not be getting on the
phone and talking to them.
If our documentation cancommunicate what we're thinking

(01:05:55):
to them, that can be almost asgood is good.

Yeah, no, that's I usually when I'm writing
notes and obviously I'm stillearly on in the in the stages
here.
But uh, I I usually at leastfor assessment and plan or, you
know, hpi, those kind ofnarrative sections.
Uh, I think of, like, if you'retalking to, like, if you're
presenting it to a doctor youdon't know, right, just any any
one individual, just to, tolower the pressure on yourself
just one one individual that youdon't know so that they can

(01:06:23):
look at it.
That's just imagine you'retalking it to them.
Um, I know some people like todictate I'm more of a typer than
a talker out loud but, um, Ithink that can kind of help keep
it uh, uh, kind ofconversational and easy to read
as well.
Yeah, um, easy to read andcomprehend.

I always think.
Again, I can't place the quoteand this is more of a paraphrase
than anything, but I'llsometimes get asked by students
or residents like how longshould my note be, or how long
should my HPI or my assessmentbe?
And you may have picked this up, I tend to give tongue-in-cheek
answers most of the time.
Pick this up, I I tend to givetongue-in-cheek answers most of

(01:07:06):
the time.
But uh, I'll say it, it shouldbe as long as it needs to be and
no longer so it's good advice.
But I mean, it's true, right,we've all read the notes that
are, you know, like literallyone sentence and just like I
don't know what, what the heckis happening here.
And then, on the completeopposite end of the spectrum,
there's this long winding notefull of extraneous information.
It's not in a chronologicalorder, right, it's a narrative

(01:07:30):
disaster.
And so you spend so much time,right, it's probably exactly
what the patient said in thevisit, in the visit, but you as
the provider, as the physicianor the APP or whomever, need to
translate that information intosomething so that when it lands

(01:07:50):
on somebody else's desk or whenthey come back to see you in
like three, six months orwhatever, you're not having to
spend 20 minutes reading theserecords that maybe you yourself
wrote to yourself to figure outwhat.
What was I thinking, you know, afew months ago?
So be kind to your future self,be kind to your colleagues, I
would say.
Is that on that front?

(01:08:11):
So any final thoughts aboutcommunication.
If, in your experience, youknow, seeing, you know,
obviously you've got yourexperiences at Cleveland Clinic,
working with, perhaps, studentsfrom other training programs or
residents who came from othertraining backgrounds, I know
communication training like thisis not necessarily universal.

(01:08:34):
It's certainly gainingpopularity in a lot of places.
Um, what's your kind of, your,your bird's eye view?
Again, just anecdotally aboutcommunication, training in
medicine and uh, where it standsfor, kind of the, the current
generation of physicians versus,so let's say, the, uh, the
older generation of physicians.
Um, and where are some areas ofimprovement in our practice at

(01:08:58):
present?

Sure, no, I.
I think that, for first of all,I loved communication skills as
a first and second year medicalstudent.
It was, I think, one of thehighlights, both because, um, I
enjoyed the practice of gettingbetter at communicating in
general and, uh, my first yearand like half a second year of
medical school was, uh, duringthe COVID pandemic, so that was

(01:09:20):
one of the few times we got tocome in and be in person
together, so that helped a lot.
But I think there's, you know,it's not training people or
medical students to communicateone way.
It's not.
We're not turning, you know,we're not teaching them all to
be the same physician.

(01:09:40):
It's more so, we're providingthem with like a toolkit and
they can choose which of thosetools they want to use and how
they want to use them withintheir own unique style.
So, in more of a way, it's moreso teaching med students how to
be themselves with patients,and that's the way that I look
at it and the feedback that Igave was mostly targeted towards

(01:10:03):
okay, this is, you know, youhave these strengths as a person
, use them and then take theseother things.
That I took away from it andtried to teach to my students
was the practice ofself-reflection.
We've talked a lot abouttalking to other people.

(01:10:30):
How do we talk to ourselves?
Good point, and that is reallyhard because the very first day
you do your standardized patientencounter and then someone you
know three of your friends aresitting there looking at you and
a couple preceptors looking atyou, saying, okay, how do you
think you did?
And everyone immediately says,well, I should have done this, I
should have done that, I didn'tlike how I did this, my eye

(01:10:51):
contact was bad, like that.
That's where our minds go, justnaturally, because we're like
we focus on what we didn't dowell, that perfectionist mindset
.
Um, and so that's the.
The hardest thing is to teachthese students, and it was hard
for me to learn myself.
To start with, what we callreinforcing feedback.
Try to stay away from positiveand negative reinforcing

(01:11:12):
feedback.
Here's what I think workedeffectively for me.
I think that my eye contact isimproved.
I think that I really builtrapport with this patient by
talking about, you know, thisaspect of their family life they
brought up.
And then here's what I wouldwork on next time or what I
could have done differently.
You know, next time I want towork on thing X thing, y,
whatever it is, and those thathas become a common practice for

(01:11:35):
me.
Every patient experience that Ihave is now an opportunity for
self-reflection.
I think I did these thingseffectively.
I think next time I would wantto work on that.
And just another kind ofcorollary to that is I try to
stay away during self-reflectionfrom the word should as much as
possible, because immediately Ishould have done this, I should
have done that.
We're kind of assigning blameto ourselves for something that

(01:11:57):
we perceive we should have beendoing, as opposed to well, I
could have done this differently.
Maybe next time I can try thatand see if it'll work better for
me.
Um, and that I feel like it'syou know, it's, it's all mindset
, it's all practice, it'swhatever works best for you.
But that self-reflectioncomponent has you know, beyond
even the uh, learning how tocommunicate with others.
It's helped me beyond medicine,beyond talking with patients

(01:12:21):
and peers, but just in mypersonal day-to-day life.

Now, those are great points.
That negative self-talk is, Ithink, definitely something that
most people in medicinestruggle with, for that exact
reason that you said right,we're all used to being high,
achieving right.
You can't be be wrong.
You have to be right always,and so anything that is wrong is
bad and it's uh, yeah, itdoesn't help, right, it doesn't.

(01:12:46):
It doesn't make you feel better, it doesn't make your
performance better.
So it is very useful andchallenging to kind of reframe
those things and I I kind ofhate this.
Right, it's become like a bitof bit of corporate speak right.
These I kind of hate this.
Right, it's become like a bitof corporate speak right.
These opportunities forimprovement, quote unquote.

(01:13:07):
But in reality, I mean, whenyou're saying it to yourself,
it's a different thing than when, like you know, corporate
saying like, oh hey, you know,50 people quit.
We have these opportunities forgrowth.
Different context, but itreally is true, right, we do
have these opportunities and youknow, it's perhaps gotten a bit
of a bad rap due to onlinediscourse, but having this

(01:13:28):
growth mindset, which ties intobeing that lifelong learner,
looking to constantly improveour skills, really important
things, and it's very easy forus to kind of dismiss these
again, like, as we said, kind ofnear the beginning, these,

(01:13:50):
these soft skills as something.
But I've known so manyphysicians where you know
outside of the clinical settingthey're super nice, super
friendly, but then you get themin, like to a patient encounter,
and they are all stiff andrigid and kind of sweaty and
nothing against sweaty people,but I am at times amongst them.

(01:14:10):
But it is one of those thingswhere it's like dude, what's
going on?
These people, their entiredemeanor changes and it goes
back to what you were saying,that they are not being
themselves.
And it is one of those thingswhere that self-talk you have to

(01:14:31):
be first Okay With beingyourself, um, to be yourself in
front of somebody else,especially when you're you know
you're engaging with someone ina vulnerable position.
Right, there's a sharing ofinformation and you know,
sometimes you're sharingdifferent experiences.
Some of those may be quitevulnerable in nature depending
on the conversation and it.

(01:14:53):
You know, if you're notcomfortable with yourself,
you're not going to becomfortable having these
conversations.
And I think something we allstruggle with when we first
enter clinical practice.
In particular, you know we'reasking about things like sexual
history, you know.
You know illicit drug usethings like this, things that
are not considered a politeconversation, quote unquote.
And so you're kind of movinginto this different realm of

(01:15:16):
what is socially acceptable,right You're.
You're assuming this mantle ofa healthcare provider and, to an
extent, right, if I'm walkingthrough the grocery store I'm
not asking, you know, the randomlady in the produce aisle like,
oh hey, how many packs ofcigarettes a day do you smoke?
Or you know, have you ever hadhepatitis?

(01:15:37):
Or you know all these thingsthat in a clinical setting would
be entirely within the realm ofconversation.
So it's this reframing of like,what is it okay for me to, to do
and to ask in this settingversus my normal social
interactions, and that that doeshave a steep learning curve and
some people struggle with that,that transition quite a lot, I

(01:16:01):
know I I did the first couple ofyears that I was, that I was in
clinical years in med schooland as an intern.
But ultimately, right, you gotto have these conversations.
So you just kind of got to tearthe bandaid off and get
comfortable with it.
I mean, it's not helpful advice, I apologize, but that was how
I did it for me and it is right.

(01:16:22):
It's one of these things whereit's a weird social phenomenon
where we're expected to quote,unquote, be ourselves but we
also have to be, you know, theface of their health care
administration, and so you kindof have to be yourself but also
be something else at the sametime.
It's this weird superimpositionof these different social roles

(01:16:46):
, so it can be hard, especiallyif you're, like I said, not
comfortable with kind of who youare.
I don't know, I got kind ofmetaphysical there for a second.
What are your thoughts aboutall that?

I love it.
I think that's really where thecommunication skills course
helped me was.
You know, if you're, it'salmost like you're performing in
a way at first right, you'repretending to be a doctor,
you're pretending to be amedical student who feels like
they're part of the care team.
That was my growth journey.

(01:17:19):
In the first you know, year ortwo, uh was realizing, okay, I
am part of the care team, thequestions I'm asking can matter,
um, and I'm not justinconveniencing this patient by
talking to them before thedoctor does um, but but kind of
realizing what, what's holdingyou back, what is stopping you
from being yourself and thatdoctor at the same time, right,

(01:17:41):
and uh, doing that in front ofuh, sort of like in a, a
environment that's establishedto be like a, like a safe
learning environment, you can doanything, you can say anything
and we're just going to give youfeedback and grow all together.
That was, that was huge and italmost like, in a way, when I
was alone with patients, I feltmore comfortable.

(01:18:01):
Like it made being alone withpatients feel more comfortable
than when I was being watched.
Oh, yeah, because, because,because it's like all of a
sudden, you're like you'reputting all this pressure on
yourself.
That's really you doing it toyourself.
It's just, this is how it works, because everyone's watching
you with open mind and, you know, supportive and everything but,
um, yeah, that for me, was, wasone of the biggest things, was,

(01:18:21):
uh, was finding myself as as acommunicator, um, and being able
to be, you know, just the wayI'm talking to you now is the
same way I talk to patients.
You know, and we joke aroundwhen appropriate and and you
know, and and laugh and commenton things and and feel like, uh,
like what we're saying is isimportant to them, right, that's

(01:18:42):
that's what it, that's what ithas to be, that that's exactly
right and that's that's actuallyone of the pieces of feedback
I've given.

Perhaps again, I can't keep from joking
it's.
It's perhaps to the point of apersonality flaw, but uh, it's
like.
You know, just talk to peoplelike they're people, right.
You know, don't turn into likea lizard person when you're in a
patient encounter.
You know, like you've forgottenwhat do humans do during normal
social situations.
And again, I know there arepeople who are like kind of on

(01:19:14):
autism spectrum and things likethat, that will struggle more
with some of those social cuesand things like that cues and
things like that.
But when someone is actingnormally outside of the room and
then their whole demeanorchanges, that's more what I'm
kind of intimating at, and it isone of those things where you
just talk to them like you wouldtalk to anybody else and that's

(01:19:37):
going to solve a lot of yourproblems, I think.
For anyone out there who's kindof struggling with that, I kind
of think back to um, you knowkind of like classical, like
ethics.
You know the big question whatdoes it mean to be a good person
?
And it's like, well, what doesa good person.
Do you know?
They like, they care, take careof their family, they are
responsible members of thecommunity, blah, blah, blah.

(01:19:57):
Uh, the rest of the details.
But you do the things that agood person does.
Does that mean that I am good?
It's the same thing forbecoming a physician.
I do the things that a goodphysician does.
Am I a good physician?
I don't know.
But at some point it's not justthe things that you are doing.

(01:20:18):
I've been reading too muchmetaphysics lately, but it's
like the doing leads intobecoming right.
So by doing the thing it's kindof the fancy version of fake it
till you make it right, butyou're not faking it, you are
doing it right, you are doingthe thing.
And so by doing the thing,eventually you I heard this said

(01:20:42):
if you want to be the noun, youhave to do the verb, and I
really liked that a little moreyou know right.
So if I'm, if I'm doctoring,eventually I become the doctor.
So, and it's one of thosethings where you kind of you
accumulate these skills overtime.
And you know, communication, aswe've said, is one of these very
fundamental skills, sofundamental it's almost

(01:21:02):
overlooked in some arenas and Ithink it's one of those things
where we spend so much timelearning about physiology and
anatomy and pharmacology and thelitany goes on forever.
Neglect this, this beginningpoint, right?

(01:21:25):
Uh, if we don't talk to thepatients, if we don't tell them
like, hey, we're doing thisbecause of this, then you know
all of it's just so much wastedenergy.
You know, we, we did the tests,we make the recommendations,
the plan falls apart because wedidn't communicate it.
Um, so anyway, uh, I, I amdiverging significantly, but I
just find it a very interestingphenomenon, you know, in the

(01:21:47):
course of like language andthought and all these kinds of
things that are wrapped up inlike the underpinnings of
communication.

I think, you know, communications become
almost even a kind of a passionof mine within the context of
education and even just myself,self-reflection, can I improve
how?
You know, how are the thingsthat I say perceived by others,
and how does that help or hurtme in my goal to to help them,

(01:22:18):
and you know it's a it's aconstant day by day journey.
We're going to keep on, keep ondoing it on my end and I hope
medical students out there keepon learning as well and keep
improving too.

Yeah, uh, what's that?
Uh, there was a Pink Floyd song, I think, out there.
It was like uh, just keeptalking from one of their less
popular albums, but that's okay.
Uh, it's a good song, but butthat's the point, right?
It is just keep talking, right,even if you're not good at it
to begin with.
Keep practice, just likeanything.
It's the practice of medicine,it's the practice of
communication.
If you don't do something,you'll never get better at it.
And I think that's that's agreat point to end on is just

(01:22:51):
just keep talking, just keepcommunicating, just keep working
at it.

I love that.

Any, any final thoughts when should
people reach out to you if theywant to get in touch with you
online, or do you have anyprojects to plug?

We've got POTS research out there.
Search for Dr Robert Wilson andyou'll find some of our POTS
work, found some interestingthings related to post-COVID
syndrome and POTS and a numberof other things.
Low-dose naltrexone we've beenworking on as potential therapy,
and then, yeah, feel free toreach out.
My email is c a n t r e c atccforg, and you know.

(01:23:31):
Appreciate you, dr Kentris, forgiving me the chance to talk
about this today.

No, this is a really fun conversation.
I appreciate you taking thetime, especially as we go into
interview season.
I know how busy that gets forpeople.
I appreciate you taking thetime, especially as we go into
interview season.
I know how busy that gets forpeople.
And you can, of course, find meonline.
Our website istheneurotransmitterscom, and you
can find me mostly on X,formerly known as Twitter, at
D-R Kentris, k-e-n-t-r-i-s, andyou can always email us from the

(01:23:58):
website as well.
Chris, thanks again.
I really appreciate it and goodluck with all the research.

Thank you.
Good luck to you as well, thankyou.

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The Art of Communication in Neurology with Chris Cantrell

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