#33 Leading the Way: Navigating Transitions in Medical Education with Dr. Michelle Kittleson

May 30, 2023 | By John Ong

Audio

Video

Michelle Kittleson, MD (@MKittlesonMD) drops pearls from her new book, Mastering the Art of Patient Care, around how to be a leader and navigate transitions in health profession education.  She shares relatable anecdotes and valuable tips on how to prepare for leadership, navigate uncertainty, and build your mentor cabinet. 

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Case from Kashlak
• Leadership development in medicine
• Senior Resident Transition
• Kittleson’s Rounds
• Encouraging Healthy Debate
• Kindness as a Leader
• Mentor Support
• Dealing with Uncertainty
• Tips to reduce micromanaging
• Take home Points
• Outro
  

Dr Michelle Kittleson is Professor of Medicine at Cedars-Sinai and Director of Education in Heart Failure and Transplantation at the Smidt Heart Institute. Dr. Kittleson is Deputy Editor of the Journal of Heart and Lung Transplantation, on writing committees for the 2020 Hypertrophic Cardiomyopathy Guidelines and the 2022 HF Guidelines, and on the Board of Directors for the Heart Failure Society of America. Her essays have appeared in the New England Journal of Medicine, Annals of Internal Medicine, and JAMA Cardiology and poems in JAMA and Annals of Internal Medicine. Her book, Mastering the Art of Patient Care, is available from Springer publishing. 

Leading the Way: Navigating Transitions in Medical Education Pearls

1. Preparation is the best way to decrease fear and anxiety about transitions; don’t worry, make a plan! 
2. Efficiency on rounds comes from pre-rounding (utilizing the EMR) and having a clear plan for patient presentations (e.g a one liner and then plan by system). 
3. Remember to bring health debate and kindness into your approaches for rounds and addressing questions from consults or colleagues.
4. Transitions are softened not only by having prepared (“don’t worry, make a plan”), but also by creating a cabinet of mentors for support, reflection, and advising. 
5. As an early attending, figure out what is and is not negotiable in clinical care and explain your reasoning. In negotiable situations, give trainees leeway by developing a contingency plan with their suggestions: if you don’t get X result by Y time, you will do Z. 

Leading the Way: Navigating Transitions in Medical Education Notes 

Leadership Development

Leadership is an important role for medical providers.  Dr Kittleson suggests that having the initiative and motivation to grow and improve is the first step.  Learning from your own experiences, your mentors, and the mistakes of others can move you forward. 

Tips for New Senior Residents

Recognize that it is scary to move into a new role, and Dr. Kittleson says it’s understandable; it should feel initially scary. Make a plan where you can transform your fears into a concrete action plan. Prepare. The more you are prepared, the better you can implement your plan with your team. 

Kittleson Rounds

Based on expert opinion from Dr. Kittleson, preparation upfront is key for everything, but especially for rounds. Consider how you want rounds to be structured and share clear expectations of that structure.  Dr Kittleson suggests focusing on efficiency in rounds.  Presentations start with a one liner and move straight to the plan by system; this allows for dedicated time to discuss the management plan, the most important aspect for each patient.  

Value of Pre-rounding

Pre-rounding helps streamline rounds because the senior resident/fellow/attending doesn’t have to use time during rounds to confirm the accuracy of what the learner shared. The rounds leader can instead focus on the learner’s presentation and management reasoning. The team leader doesn’t necessarily have to go bedside to see the patient, but information in the electronic medical record (EMR) can be extremely helpful for pre-rounding: review vitals, new orders, nursing notes from overnight, etc.  Pre-rounding allows the leader to prepare their teaching plan early and devote more time to teaching when actually on rounds.

Efficient Presentations

Have a systematic approach to the assessment and plan.  Presentations start with a one liner and move straight to the plan by system. 

1. Start off by stating the system, for example, cardiology
2. Then state the problem within that system, e.g. heart failure.  
3. State whether the problem is getting better, worse, or staying the same, e.g. the volume status is improving compared to yesterday. 
4. Then provide a plan for the day and the reasoning behind it, e.g. today I’m going to continue furosemide 40mg BID because the patient had a good response yesterday, so the same dose today should achieve our goal of two liters negative. 
5. Bonus points, say at the end, the goal for this hospitalization for the patient. E.g. We hope to discharge the patient home on oral therapy, but we are not there yet; still need IV diuresis because I am estimating the patient is still 5 liters up.

Encouraging Healthy Debate 

It is important to be able to talk through disagreements and come to a place of consensus where the patients, trainees, and attending physicians all benefit. Dr. Kittleson recommends normalizing the elephant in the room, with enthusiasm and kindness. E.g. “I sense that you don’t agree with me, and I think that’s great, because I love to debate medical issues. Tell me where you’re coming from. Let’s see where we can talk about it some more and make sense of this issue.” By normalizing healthy debate and discussion, trainees learn that respectful disagreement is possible; rounds become a safe and brave space where everyone is learning without fear and people feel comfortable asking questions. It’s mutually beneficial: the rounds leader can comprehend a medical topic better by having to explain their reasoning and the evidence, and the team may come up with something the team leader hadn’t thought about, ultimately leading to better patient care.

Kindness as a Physician Leader

Dr. Kittleson shares an anecdote about when she was a fellow, she would answer night calls with “what is your emergency?” One time when she called her childrens’ pediatrician after hours, the on-call clinician answered with “How can I help?”  She learned from this that being rude will not stop people from calling, it just makes the call more unpleasant. Dr. Kittleson teaches that when you start out from a place of openness and kindness, it allows for a more productive and thoughtful conversation. 

Dr Kittleson highlights the power of defending your team. She recommends talking to the person who is not respecting a team member directly, especially if it is someone you supervise.  If you have a concern about how a staff member who is not in your chain of command is treating one of your trainees, talk with that person’s supervisor and ask the best way to deal with the situation. If there is disrespect coming from another physician in a different department, similarly, go to their supervisor.

When you see a learner or team member struggling or overwhelmed with whatever duties they have in front of them, rather than offering to help, make a concrete plan to step in and help. 

Challenging Transitions

Transitioning to be a 3rd year medical student, 2nd year resident, first-year fellow, or new attending is hard!  These are new roles requiring new skill sets with increasing levels of responsibility/leadership. Although it can be stressful, the best way to mitigate these transitions is to start with a plan. Once you make your plan, envision what is involved in success. Remember, you can always look to your past (successful) experiences and trusted mentors whenever you need help (Deb 2021).

Mentor Support

A mentor is a role model, someone you admire. When advancing in your career, it is important to establish a cabinet of mentors to support you in different situations.  A mentor may be most valuable to you in different scenarios, such as discussing challenging clinical scenarios, nuanced medical topics, interpersonal issues, work-life balance, or research endeavors. 

How to Establish Mentors

1. Ask if you can meet with them to get advice on X, Y, or Z
   1. If they say no, then you narrowed down your mentor pool
   2. If they say yes, ask the questions to see if they’re a good fit
2. Don’t be intimidated by people who may be more senior than you
3. You can learn a lot about people and help them open up by asking, “how did you end up here (your current role, position, career trajectory)?”

Things to Model

1. When dealing with uncertainty, recognize that you can’t know everything
   1. Know where to look
   2. Ask the right questions
2. Calling a consult
   1. Call the consult early
   2. Know what question you’re asking the consultant
3. Ongoing self-development
4. Patient-directed learning

Tips for Early Attendings to Avoid Micromanaging

Focus on optimal patient care.  Figure out what is and what is not negotiable.  When you encounter a situation where there is a non-negotiable situation, give an explanation as to why that situation cannot be handled differently.  In negotiable situations, you can give your trainees some leeway by having them develop a contingency plan. If you don’t get X result by Y time, you will do Z. 

How can we support our trainees to become leaders?

A great leader can do their supervisees’ jobs as well as they can, they just don’t do it because they have taken on leadership roles.  A great physician leader provides excellent patient care and understands what it’s like to be a “foot soldier”. 

Take Home Points

1. Don’t worry and make a plan
2. When in doubt, ask for help
3. Don’t ever forget or take for granted the privilege we have in the ability to improve patient care and save lives

Other Stuff

Links

1. Mastering the Art of Patient Care by Michelle Kittleson 
2. Romantic Comedy by Curtis Sittenfeld (who also wrote Rodham) 
3. Easy-Bake Battle: The Home Cooking Competition on Netflix
4. Is it Cake? on Netflix

Goal

Listeners will appreciate the nuances of leadership skill development in medical education,  specifically as it applies to role transitions and teaching on a team. 

Learning objectives

After listening to this episode listeners will…

1. Recognize the role (and components) of leadership development in health professions education 
2. Distinguish the components that make for successful leadership transitions in medical teams
3. Describe the interplay between growth of skills as an educator and leadership skill development

Disclosures

Dr. Kittleson reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Kittleson, M. Heublein M, Kryzhanovskaya E. Ong J. “#33 Leading the Way: Navigating Transitions in Medical Education”. The Curbsiders Teach Podcast. https://thecurbsiders.com/teach.  May 30, 2023.