The Art of Communication in Neurology with Chris Cantrell

In this episode, we are joined by Christopher (Chris) Cantrell, a medical student from the Cleveland Clinic Lerner College of Medicine, to discuss the art of communication in medicine, especially in neurology. 

From provider-to-patient communication and peer-to-peer conversations to documentation and self-talk, we talk about it all! 

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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Chapters

• 0:00 Introduction to Medical Communication
• 8:30 The Fundamentals of Motivational Interviewing
• 20:24 Patient-Centered Communication Techniques
• 35:19 Navigating Communication Challenges in Neurology
• 54:43 Understanding POTS and Patient Validation
• 1:06:45 The Art of Asking Better Questions
• 1:16:18 Feedback and Communication Between Colleagues

Transcript

Dr. Michael Kentris: 0:02

Hello and welcome back to the Neurotransmitters, your podcast about everything related to clinical neurology. Today I am joined by Chris Cantrell from the Cleveland Clinic Lerner School of Medicine, a student there, I should say I don't want to have any false accreditations, as it were. What's the term? We're looking for, stolen valor but Chris and I met through some mutual contacts at the American Academy of Neurology meeting this last spring and some other mutual friends, and he's got some interesting experiences that I thought would be potentially educational and beneficial for you, our dear listener, and today we are talking about talking, or communication as it would be more properly understood. So, chris, welcome to the podcast.

Chris Cantrell: 0:52

Thanks for having me, dr Kentris, excited to be here with you.

Dr. Michael Kentris: 0:56

So I was very interested. You know, anyone who knows me knows that I'm always interested in the way that we communicate things, 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 about how you came to be interested in the art of communication in a medical setting, and kind of how your school also fostered that ability to develop those skills.

Chris Cantrell: 1:28

Yeah, so I'm, like you were saying, still a medical student, fifth year now at CCLCM, planning on applying into neurology, hence why I'm on this kind of podcast topic, I suppose.

Chris Cantrell: 1:41

But my interest in communication really came about as part of my med school.

Chris Cantrell: 1:47

So there's a culture of self-reflection that they try to instill in their students from really early on.

Chris Cantrell: 1:55

It's taught, it's not just talked about, it's really a skill that's to be developed.

Chris Cantrell: 2:01

And so early on in my first and second year, kind of experiencing that powerful benefit of strong communication and teaching, and from my colleagues as well, my fellow students, and seeing how much that helped me to improve. And then, on the other hand, as I aged in med school and starting to teach some of these younger med students who are just learning how to do these things, seeing how much it helped them to try to use those same tactics and kind of evolve and keep improving myself as a teacher, and seeing how much they benefit from that and in their own interactions with patients as well, like coming back and telling me hey, I tried this thing that we talked about and it seemed to work really well. So that's where I realized how important communication is as a teacher, as a sort of practitioner of medicine at this stage getting there, but it really made me more interested in it and to keep kind of thinking about it as a core principle of of medicine and just being, I guess, a human.

Dr. Michael Kentris: 3:08

Yeah, that that is one of the things that I think gets neglected. You know, all through I think this is a universal experience for everyone who goes through medical training is you're? You're kind of the fly on the wall as a medical student and you're watching a patient encounter a conversation with the physician that you're kind of the fly on the wall as a medical student and you're watching a patient encounter a conversation with the physician that you're shadowing or rotating with and you're just like, ooh, this is really awkward and painful to watch, and I think it speaks to what you're saying, right, these soft skills quote, unquote are something like oh well, you know, you made it in med school. You're at least semi-intelligent, so certainly you can talk to another human being in a rational and reasonable way. Not so much the case, right, this? This is a skill that needs developed and worked on, just like any other kind of ability.

Chris Cantrell: 4:03

Yeah, so, um, early on in our med school they get us started in a communication skills course. So there's two phases to this. There's the first year course and the second year course. That first year course really focuses on just the ground level basics, fundamentals of how to introduce yourself to patients, how to set up what's going to happen in the visit, how to introduce yourself even just as a 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 to see the doctor. The basics of the history how do I do a social history? How do I get an HBI? Things like that. How to deal with patients who might be on the chatty side and redirecting without being rude. That's, that's one of my favorites. Uh, we, uh, one of our standardized patients, uh is, uh, you know the, the archetype of the, the grandmother who wants to give, give, give you cookies and be like oh well, I'll bring by, you know, cookies for you. How do you redirect? How do you redirect from that?

Dr. Michael Kentris: 5:03

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

Chris Cantrell: 5:08

So all these kind of situations we throw students into it's all in a small group setting and you're getting feedback constantly from your peers as well as faculty preceptors and or a student preceptor which I was lucky enough to serve in that role last year as a student preceptor and then in your second year of med school they go on to kind of more advanced skills where you get into more motivational interviewing smoking cessation counseling, delivering difficult news, things like that where it's you know you really don't want to be learning how to do it on the job, things like that.

Dr. Michael Kentris: 5:45

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

Chris Cantrell: 6:04

So for me, I think of motivational interviewing as right. So it's an interview, we're still trying to get information, but there is some kind of goal behind the questions that we're asking. We do you're still taking your cues from the patient, but ultimately we're trying to direct them some towards some sort of better health outcome, and I think the reason I like the kind of motivational interviewing name for this skill is that it really does come from the patient. It's like to use the example of smoking cessation counseling. It's evaluating how ready are they to make changes, what stage are they in, what would it take to get to the next stage? And uh, um, kind of taking that longitudinal approach of not okay, I'm just going to tell you to, 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 to uh be ready to make these, these kind of lifestyle changes.

Dr. Michael Kentris: 7:28

Gotcha. So in my mind I almost envision it like a form of kind of like Socratic teaching, where you're asking them questions like well, do you want this thing? Well, very often you know that like the medication adherence whole conversation, which you know 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 kind of lead to outcome A versus outcome B. If you want this other outcome, then you kind of ask them to analyze, like how are your decisions leading you towards or away from what you actually want?

Chris Cantrell: 7:49

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

Dr. Michael Kentris: 8:10

So, yeah, and I I almost kind of link it in right, we tend to think of the phrase uh, for those who work in medicine, our goals of care, right, Almost has like a, a connotation that we're talking about 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 I was like we should probably get some additional imaging to kind of make sure that we aren't missing anything. And he's like I don't want any of that. And I was like, well, you know why not. And he's like, you know, every time, every time I have testing, they put me in the hospital. And it's like, well, sure, I can understand that, Uh, but you know he was very adamant, he didn't want testing, et cetera, et cetera. Right, so those are his wishes.

Dr. Michael Kentris: 8:53

He has, you know, capacity for decision-making and so on and so forth. And so, while you may not agree, right, this is kind of going back to our principles of medical ethics. Like he has autonomy and has the, you know, the right to make his own decisions. And so it does become one of those things where you have these conversations and you know, yes, you aren't going to always agree with your patients Like that is a hundred percent going to happen, and I think it's it's a question of you know, does this patient understand? Have I communicated right? To come back around to the theme of the show, have I communicated the information and the consequences or potential outcomes of these different paths in front of us? Then that's really all you're doing is providing advice, and that's, I think, a lot of where you know a lot of physicians that I see where they get really frustrated with patients and they make them sign out of the hospital against medical advice and kind of these like semi punitive types of actions really just comes from a lack of communication about, about this.

Chris Cantrell: 10:02

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

Dr. Michael Kentris: 10:25

And I know a conversation that I'll I'll often have when I'm running in the 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 of here. I'm like, well, you know, no one's keeping you go if you're willing and we can kind of start off a conversation. But I'm always very upfront of like I'm not keeping you here, no one's holding you here against your will. Again, assuming they have appropriate medical decision-making capacity and all that, and I think that, depending on if you have your kind of stereotypical, old, curmudgeonly man, that helps break the ice a little bit.

Chris Cantrell: 11:11

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

Dr. Michael Kentris: 11:16

She drug him in here against his will. That's the usual scenario, right? But I think it's important to make sure that you do educate people about their options. If they know that they can leave if they really don't want to be here, that does, I think, at least subconsciously help them buy in a little bit to getting what tests you recommend and things of that nature, so that you can move towards hopefully mitigating those risks and providing them appropriate medical treatment. Again, that's my totally non-evidence-based perspective, just from clinical practice.

Chris Cantrell: 11:55

It's practical. It's practical, but I agree, I think some patients have a sort of they sort of perceive medical advice as coercion, depending on how it might be, might be offered, kind of like you're saying, but really giving, giving them their options. And then one thing I think about with our old man drugged in by his wife, as you were saying, is knowing when, when to pick your battles by his, his wife, as you were saying. Uh, is knowing when, when to pick your battles.

Chris Cantrell: 12:26

I think that's kind of a trick, one of those nuanced aspects of motivational interviewing of you don't have to fix everything all at once and say, okay, I know you don't want to do this thing, but how about we do you know this other thing that we wanted to talk about? Right, we'll get, we'll get back to the smoking next time, right and we'll. But let's take this medication, we'll see how goes. And then let's revisit that at the next visit, because not everyone's going to be able to change everything with just a snap of their fingers, very true, or want to. You know most people being fairly resistant to change. I think is, you know, a fair characterization. But yeah, no, I think just taking things step by step is really important.

Dr. Michael Kentris: 13:04

Absolutely. Now we talked about motivational interviewing and then, to be honest, that's the one I hear about the most. But, uh, what kind of other interviewing styles are out there? Generally speaking, I don't know if they have as a as clear cut of names or uh, disciplines or anything behind them.

Chris Cantrell: 13:21

Yeah, and I'd say the one that we hear the most about is probably motivational interviewing. Um, I think there's. There's certainly other ways to go about it. Um, I'm not really sure. Like I said, I don't know that there are a lot of names aside, assigned to them or at least taught. Uh, in terms of you know, kind of what we went through, um, but in terms of like talking to patients specifically right now, there might be other ways of of kind of what we went through, but in terms of like talking to patients specifically right now, there might be other ways of kind of looking at interviewing or, you know, if you even loop feedback into the interview kind of sphere.

Dr. Michael Kentris: 13:54

Right, and yeah, that brings up a good point. We're talking mostly about patient provider types of communication and I think in the second half, patient provider types of communication and I think in the the second half we'll move into like peer communication, which is also very important, uh, given that medicine is very much a team sport. But um, before we move on to that, one of the things and we kind of danced around this a little bit is that we'll very often see patients from different backgrounds, whether that's cultural, educational, different kinds of preconceived notions and things of that nature different intellectual people, especially in neurology, people with different, maybe intellectual disability. So how do you go about, or what kind of evidence do we have, to suggest different forms of communication in these settings, or trying to connect with the appropriate level of information, versus diluting our message too much where the patient's not actually receiving that information in a meaningful manner? Mm-hmm.

Chris Cantrell: 15:02

Yeah. So I think there's a number of things that can help there. Uh, for me, I always, no matter who it is, I lead, let the patient lead to some extent. Um, so that's where question asking, uh, leading with what's your understanding of your condition or what have other. If you're in the hospital, you come in, you've got a console, what have the doctors told you, um, instead of just assuming that they know thing, you know X, thing Y, thing Z about their condition. So I always start there.

Chris Cantrell: 15:32

That generally will also give you a pretty good baseline of a how well they understand their condition, be their level of health literacy.

Chris Cantrell: 15:41

And then from that you know, because obviously you have to make some kind of judgment call on how you're going to describe what you need to, what you're going to say about their condition, their medications they need to take, treatment planning and then teach back. I think is also kind of a helpful thing. So after so, summary statements on your own part while you're doing it and then saying at the end you know, can you explain to me? Kind of a helpful thing. So after so, summary statements on your own part while you're doing it and then saying at the end you know, can you explain to me kind of what we just talked about, just to make sure we're on the same page, or what's your understanding of of kind of where we're at now? Uh, just to get that kind of extra confirmation and to make sure that they know it well enough, uh, both to uh, uh to understand what's going on and to communicate it to you know their other, you know health physicians, if they bring it up, or or anything like that.

Dr. Michael Kentris: 16:29

Right, I can't tell you how many, how many visits I've had in the office where someone comes in and you know they unfortunately their records are not not in the office and they had their care at 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's going to be challenging. So you end up having to really dig for that collateral information which I think neurology is kind of a unique thing, because so many disorders affect people's memories and recollection of events. They may have memory loss from that specific period of time, or maybe they had a more long-term neurologic disability or deficit from a stroke or some other kind of injury, and so you're really leaning heavily on that patient's caregiver whether that's family, friends, what have you? And those outside records from wherever their care was given. And that's very challenging and we see it in the hospital as well, when you know if their family member is not there at the bedside. You got to track down a phone number. Hope you get through, hope that person you get through to knew the person well enough that they can tell you about what was going on beforehand. And so there's all these like things where you know you're sometimes kind of operating in a little bit of a fog of war, where you don't really know all the details that would really inform your clinical decision making. Um, and it can be, it can be quite challenging. I think neurology is somewhat unique. Probably psychiatry also faces a lot of that sort of thing, right, anything dealing with the brain you kind of you know, to borrow from literature you kind of have sometimes an unreliable narrator, and that's especially early on in my career. I found that to be a very challenging thing.

Dr. Michael Kentris: 18:19

I remember, if I may, indulging an anecdote. Remember, if I may indulge in an anecdote. I had this patient who came in and, uh, you know, she had had a bilateral occipital lobe stroke, not a huge one, but uh, they were present, right, and I go and assess her, you know, I'm checking her visual fields. All of a sudden she, you know, she's counting the fingers appropriately, all this kind of stuff, 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's like, are you sure? I was like I think so, and right, like with every question, I begin to doubt myself a little bit more. And it's like, and he just says we'll see. And so we go into the patient's room and he just asked her, like what color is my shirt? And she like bombs. And she had just guessed like the right number of fingers, like three times in a row and I was just like, oh my gosh. So I felt like a complete fool.

Dr. Michael Kentris: 19:27

Question your own assumptions.

Dr. Michael Kentris: 19:27

Um, if you think that the person is having impaired communication, whether that's them taking in the information or giving the information of their own history to you, and that's something that, uh, whenever I'm like rushing in the hospital or I'm not taking the time that I should be, you get burned on it.

Dr. Michael Kentris: 19:42

It's, it is a perennial fact, and so it just, it reemphasizes, right, like I remember when I was an intern doing my internal medicine, we spent so much time looking through records and labs and you know all these CTs and whatnot, and I find in the practice of neurology that ratio is flipped and we spent, I spend, you know, like an hour talking to the patient and and I'll spend, depending on the person, 10, 15 minutes looking at their records and images, depending on how much workup they've had in the past. A lot of times you find that the interviewing is where a lot of your diagnostic decision-making happens and a lot of that explanation of recent events. A lot of your your diagnostic decision making happens and a lot of that, uh, explanation of recent events. And a lot of times, as the neurologist you're asking I a lot of times I preface this when I'm talking with patients like I'm going to ask you some strange questions now because, like, especially for like seizures and things like that.

Dr. Michael Kentris: 20:40

Right, you're asking about all these weird experiential type things and they're like I mean if you're if you're hot on the trail, right, you're asking about all these weird experiential type things and they'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 weird burning smell.

Dr. Michael Kentris: 20:52

It's like that's so weird and it's like that happens right before you lost consciousness.

Dr. Michael Kentris: 20:55

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 very satisfying part of the job is when you can, kind of you, you start asking these questions when you have a clinical suspicion of some entity and, yes, it's important for diagnosis, but it also, I think, provides a very strong rapport building event with the patient because like, oh, finally here's someone who's asking me about these things that I've been experiencing and is taking the time to listen and not just, you know, writing it off and saying it's all in my head.

Dr. Michael Kentris: 21:32

And you know a lot of these kinds of stories that we hear, especially from you know people who are like younger women or minorities or things like this, where they kind of get dismissed a lot of times when you have these strange neurologic symptoms. So I found that again right in my own practice that this is one of the more satisfying things is when you're able to provide this answer to someone who's been kind of looking for something to explain these strange events in their life for months, or sometimes years speaking of uh, patients who are misdiagnosed or not listened to.

Chris Cantrell: 22:12

Uh, a lot of my clinical work and research work has been in pots postural orthostatic tachycardia syndrome and uh, a lot of young females, you know 20s, 30s have had symptoms, you know, unexplained since teenage years. Or you know, close onset after a GI or viral respiratory illness. And you know a lot of them are told because you know symptoms being palpitations, syncope, loss of consciousness, very heterogeneous. You know gi stuff, uh, changes in sweating. Just you know autonomic symptoms. The autonomic system is everywhere. So you get, you know, a whole lot of different signs and a lot of them have migraines, ibs, you know sort of uh, those kind of things. So a lot of them are told it's just anxiety, you have an eating disorder, even though they have, you know, poor gastric emptying.

Chris Cantrell: 23:05

Uh, you know they, they get, they are, they feel not listened to and by the time they get to us, even just uh, having someone listen to what they're saying and not just immediately tell them oh, this is what it is, um, even that alone builds an enormous amount of trust. Um, which was surprising to me at first because I was like they must really have felt, you know, not listened to or ignored or dismissed, kind of like you were saying. To get to that level that even just being listened to and it's not like we tell them, oh, we have the fix, you're going to be immediately better, right, you know, this is one of those. You know, can be kind of chronic. Uh, you know, it can be kind of chronic.

Chris Cantrell: 23:46

It may get better, it may stay the same, it may get worse, um and but having that kind of answer of, okay, we're going to, we're going to test you, we're not going to turn you away, we're going to treat you symptomatically, um, because that's the best that we have right now. But, uh, and then you know, lifestyle management and patient education. We do online virtual shared medical appointments that people can hop on, almost like a just kind of almost like a Zoom class. I guess you could say it was just like we're going to have a topic of the day. Talk about here's how you can exercise when you feel like you can't get up during the day. Here's how you can modify some of your diet. Here's how you can, uh, you know, modify some of your diet and uh, even even that alone just listening to people and making them feel heard can have an incredible impact on their health, right, yeah, right.

Dr. Michael Kentris: 24:34

We always think about communication as us talking, but sometimes it's just listening and, uh, yeah, taking that information in, and that's the thing that I always think is the most I shouldn't say the most interesting. But something that's very interesting is that, you know, through the course of our medical training, right, we learn all of these $5 words for all these different conditions and so on and so forth. We have the person sitting in front of us who has some sort of experience, and that's the strange thing about neurology and one of the phrases I really liked from Dr Aaron Berkowitz's I think it's the preface of his textbook. He talks about the practice of imaging negative neurology, which I think is where the art of neurology really lives.

Dr. Michael Kentris: 25:24

There's no specific test. It's for us to recognize the pathology and the way the systems are supposed to work and when there's a deviation that could be causing these symptoms. But it's taking the way that they describe their symptoms and translating that into what we know on kind of our more reductive medical side of things, and be like, can I extrapolate the way that they're describing these things into something that makes sense from like a pattern, more systemic kind of description and it's challenging, right, it takes time, and that is the thing I think in modern healthcare that we really lack the most is the time to sit and talk with these patients for a long time, and a lot of these patients right, if they're going to their 15-minute family doctor appointment. Have you ever had a POTS interview that was less than those 15 minutes or less?

Chris Cantrell: 26:23

They're scheduled for at least an hour usually.

Dr. Michael Kentris: 26:26

So, yeah, that's exactly what I'm saying. Right, it's this information, right it's. It's very, by its nature, it's kind of nebulous, there's a lot of vagueness to it, and that's right. That's kind of the nature of how our body interprets some of these symptoms, depending on where they are in the abdomen or the chest or things like that and they may not be like. Oh yeah, you know, it hurts when I push on my shoulder, right, that's, that's pretty easy to to suss out, uh, relatively speaking. But but it becomes this thing where you, if you don't have the time, you're not going to make the diagnosis and you're not going to be able to help your patient, and I think that's that's just as frustrating for for someone who cares about that sort of thing, uh, but yeah, it is. It is one of these things where taking, taking their information and, like you said, I think one of those, those arts of communication is like, how can I ask the same question like five different ways? Communication is like how can I ask the same question like five different ways?

Dr. Michael Kentris: 27:28

Uh, in as much as like, if we think of like, say, like chest pain, like, like, as an example, right, I was with my, my mom, uh, a year ago and she had a bit of a cardiac event. And I was sitting with her, we were, you know, she had uh been in the icu, uh, you're doing all right, she's fine now, thankfully. But, uh, but the, the intensivist, came in and like, oh, you have any chest pain or, uh, shortness of breath or blah, you know the typical review of systems, type litany. And then the, the icu fellow and the cardiology fellow and the cardiologist and the endocrinologist, right, and so, like like five, six people in a row ask my mom if she had chest pain and then, like after the fifth person she turns and looks at me, was like, what do they mean by chest pain? And I was just like, oh, my god, um, so, so it's one of those things, right, where we we assume that people know what we mean, but in reality this is not always true.

Dr. Michael Kentris: 28:23

And she's, you know, she's an educated lady, right, she's got a master's degree. Uh, she's a school teacher, you know, she's, you know, high functioning in the overall population. Bell curve, simple, like chest pain. Then what, uh, what can we expect for for someone who's, you know, less educated or less involved with the medical system and all that kind of stuff, and so it really is one of those things where, if the answers this is one of those things I always say when I have, like you know, students or trainees with me is like if it doesn't make sense, then something's wrong. Either you're not getting the right information or your your differential diagnosis is missing something, and so you usually have to go back, get more history right, ask more questions, and I find that's really you can't ever really go wrong by asking more questions.

Chris Cantrell: 29:23

I found yeah, I think the more, the more questions I ask, usually the better I feel I understand. You know the person that I'm talking to. So that's that's always my default. And yeah, just really getting their perspective on the issue, like you said, and then just drawing from misunderstandings like that, remembering I've definitely had had that situation where I ask about chest pain and they say, well, not pain, really more of a pressure. And then I'm like, oh geez, how many people have said no chest pain, but felt a pressure, which is, you know, treated not too differently, as I understand, and it's right, you know, in cardiology.

Chris Cantrell: 29:58

it's like okay, we got to look at it yeah so, um, just asking any chest pain or pressure or just making little adaptations like that as you pick up on these things can only benefit without really the cost of increased. That's not that much time to add a couple additional words for something that may be understood by a lot of people.

Dr. Michael Kentris: 30:19

Right, yeah, I find one of my I should say one, a couple of my most used questions in the course of an interview, when things aren't straightforward, clear cut, is what do you mean by that and tell me more about that? And I find that those usually open the door to some more information. Right, and I'm not an open-ended question purist by any stretch of the imagination there's definitely times where I just want you to say yes or no to certain things. But when you're on the hunt for the diagnosis, right, like when you're in the land of strange things and vague symptoms, you definitely have to be a little bit, 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 like goosebumps, uh, it just really. Uh, it's just like, oh, I'm hot on the trail and uh, I don't know, that's, that's what keeps me coming back to work every day, I suppose the goosebumps moment, uh, yeah, no one.

Chris Cantrell: 31:28

For me. That that, um, your story reminds me of is dizziness. So many different things can people just describe as dizziness, and so the way that, uh, that I was kind of originally taught to and adapted to, uh to someone would say, oh yeah, I feel dizzy. So asking well, what does dizziness mean to you? Or I'll use this for other symptoms too of like, OK, well. They'll say, well, I feel off. Ok, well, what does off mean to you? Instead of saying, well, what does that mean? Or you know, it keeps it less skeptical for me. Or like, okay, well, you know what does off mean. It's more so. Just, okay, what does this mean for you? Because a lot of people will will, I think, hone in on these certain words of like okay, well, I'm having an off day, or I'm having uh you know a goofy day or a wonky day, like the number of times I've heard those different words.

Dr. Michael Kentris: 32:22

Yeah, and then you find out, oh, I keep bumping my right shoulder into the door jam, or my right foot keeps tripping on the stairs, right, it's something like my leg's cramping over and over again and I can't straighten it out. Oh well, that's not just off, is it? Yeah, it definitely, it's all that. Again, this is one of my mentors from residency. She would always say what company does it keep? Right, everything is contextual and any symptom in isolation may not mean that much, but it's when you ask around the symptom you know, and that's where the medical training comes in. Right, it's like oh, someone says dizzy, well, I got to think about their hearing and their swallowing and their coordination and you know, maybe the strength in their legs or their sensation in their legs, right, all these things that could manifest as quote unquote dizziness, and you have to assess all of these systems that we know play into balance and walking and so on and so forth, right, so it goes from dizziness to like now I'm investigating a peripheral neuropathy, right, or maybe you know some sort of vertigo or what have you. So it it really does depend, right, uh, and it's. It's one of those things where you, like you said you just, you ask more about it. You ask kind of around, like if you have your central chief complaint at the center of that bullseye, like what's the stuff that are kind of you know in the next circle out, and sometimes that can point you in a different direction. My analogy is breaking apart, but but, uh, but it really does matter, uh, in terms of making sure, right, I think we've all, and I'm sure you know, I know you're early in your career right now but we come in, we think, oh, and this happened to me just recently Like, oh, we come in, we think oh, and this happened to me just recently Like, oh, you know, young person, new onset seizures, had the MRI, the EEG, everything came back normal. Um, second event. So we, you know, started some medication, blah, blah, blah, came in and now we're seeing like, oh, like more seizures, totally took a turn out of left field there.

Dr. Michael Kentris: 34:32

But it's one of those things where, when things aren't behaving like, you expect them to, knowing the natural history of these different conditions and again, talking with the patient, at the beginning it's like, hey, if you notice. I think it is this condition. If things worsen, if we start seeing some of these other symptoms, that's going to be wrong and we have further testing that we need to do. So setting expectations I think that's probably one of the other things that are like, like you were saying earlier, right, like this medication.

Dr. Michael Kentris: 35:02

Right, blood pressure medication probably not going to make you feel better, but hopefully it keeps you from having a heart attack or a stroke and unfortunately, right so in our world, like multiple sclerosis type treatments. They may not make you feel better per se, but hopefully they keep you from having recurrent flares. And setting those expectations up I've had a number of patients over the years that I've seen in the hospital for a flare and it's like, why did you stop taking your medications? Like I just wasn't, you know, it wasn't making me feel any better. I'm like, yeah, it probably won't. Um, and so right, the, if you don't tell the people who you're prescribing a course of treatment to what it's going to do, then they're going to have false expectations and there'll be less adherent with your recommendations and you kind of get this breakdown of the treatment, the treatment uh plan for for these people and it can wind up causing further harm.

Chris Cantrell: 35:57

Yeah, uh, I absolutely agree with that. I think even even most of us in med school can relate to the uh, the person who came in and wasn't taking their blood pressure meds or um, whether or not you know, and then in investigating I think also this is important Uh, if they say, oh, I wasn't taking my blood pressure meds, asking why and delving into that because it could be access issues, right, and you know, that's one we see frequently as well.

Dr. Michael Kentris: 36:23

I see a lot of people it's like, oh, you know, it's like, oh, that medication costs like $200 a month. I couldn't afford it, right, that's a terrible story to hear, but it's not uncommon, and so is it the better medication. It might be the better medication, but the best medication is the one that the patient can, can get and can, can tolerate. So, uh, kind of a joke that I. I mean, maybe it's in poor taste, but, uh, you know, I, I do have.

Dr. Michael Kentris: 36:53

You know, we get a lot of breakthrough seizures, most often from med compliance, and I'll be like it was, like, oh, you know, it's like, well, it doesn't work if, if you don't take it, and you know, as you said, sometimes they have side effects, sometimes they they don't feel well on the medication. So then you do have to dive deeper into it and and ask them like, well, sometimes you can change the dose, you can change the frequency, right, there's a lot of different ways you can kind of uh, uh, work around those issues if you find out what they are. So it's not just enough to say like, oh, they weren't taking their medication, this patient's not compliant, right? Uh, it's the patient's fault. Uh, it could very easily be the doctor's fault if they weren't addressing what concerns the patient brought to them last time around. So it's definitely important to go to those root causes.

Chris Cantrell: 37:40

Yeah, for sure, and I think, especially with some of our POTS patients figuring out their symptomatic treatment, some people prefer certain side effects to others, depending on what's more important for them. If something has GI side effects effects suddenly like, okay, I can't deal with any of that, or my you know, my POTS GI symptoms are really bad, um, then you just got to find something else that that works better for them. So it's kind of that, and and I think that's also an opportunity for rapport building in both listening and saying, okay, I understand, this doesn't work for you, let's find something else that does. If, if there's a good option available, of course, um and uh, you know, really just keeping that teamwork mindset and and setting up that expectation for the patient of like, okay, my doctor's working with me to figure out what's going to be the best overall kind of combination of side effect inducing, uh, drugs that I'm gonna to to, you know, kind of optimize quality of life while also treating my condition.

Dr. Michael Kentris: 38:37

And that's, that's. That's the other thing. You know, it's kind of frustrating to hear about Um. I think again, one of my mentors during training uh, the practice of neurology is humbling, right in his words, because you're wrong so often. But, um, and I found that to be true, uh, unfortunately.

Dr. Michael Kentris: 38:59

But one of the things, like you know, a patient will come in like oh, I'm, ever since I started, you know, whatever medication, I've been having this side effect and I was like, is that? And they would ask like you know, is it possible? I'm like, and I was like, it usually doesn't do that, but you know anything possible. So you definitely have to right. There's what we read in the package inserts for these medications and what's reported by the FDA and all that jazz. But there's so many variables that we can't account for realistically. So it's always good to keep in mind. You know, could this be a side effect? Well, sometimes you gotta do a little trial and error, uh, try some things out and see, and if the set, you know symptom goes away when they change medications or come off, something like, yeah, I guess it was um.

Dr. Michael Kentris: 39:47

So I've certainly, you know, seen some unusual side effects to things that we kind of use pretty routinely in neurology over the years that I was like I did not expect that to be the cause. Um, like someone had like the severe anemia from from levotiracetam or kepra. Uh, like we you know rarely will see like some thrombocytopenia from it uh, pretty uncommon. But you know they took them off the meds, blood count popped right back up and you know can't explain it, don't uh, don't know why. So it's one of those things where it's like I really wouldn't have expected that to be the cause and it was. So I think it's again tying back 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't understand in terms of like mechanism or cause or ideal treatments. So it really does keep you humble. Uh, I will say yes.

Chris Cantrell: 40:50

Well, that's what I was saying, just like you were. You were mentioning before about your mentor saying neurology is humbling. It certainly is, and, uh, I think we got to learn to, uh, to not anchor too hard on what our you know, what our thoughts are and and uh, uh, you know something that that I often will tell patients is is that they know their body best. They may not know their condition or how to treat it the best, right, but they know what they're feeling, um and uh, as long as you lead with that, now I know there's, you know, malingering and factitious, and you know, sometimes things happen those, those ways, but that shouldn't be at the forefront of your brain. No, generally speaking, when, when dealing with, with patients, of course, so giving them that kind of validation of okay, I hear you, and then you got to take their, their kind of world of living with the condition in our world and trying to understand it and treat it and find the way to get the best. That is much maligned in the medical community.

Dr. Michael Kentris: 41:40

But if we're talking with our colleagues or other medical professionals, whether they're more senior, more junior, so let's take your own experiences. You know, going through this training program, right, you were providing feedback to more junior medical students as they're going through this training program and you yourself were on the receiving end of it previously. So what, what does that look like? What are best practices?

Chris Cantrell: 42:17

Yeah, so it. It even starts very right at the beginning. First year you're giving peer to peer feedback. Same level, same class, your brand new friends. You've got to tell them here's what I think you're doing effectively and what I think that you could do better. And that in itself is a jarring opening to uh, to med school, because you have to learn how to balance. I want to tell this person they did great. I want to give them something maybe they can work on, but I also don't want to hurt their feelings.

Dr. Michael Kentris: 42:45

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

Chris Cantrell: 42:49

Generally not.

Dr. Michael Kentris: 42:49

Okay.

Chris Cantrell: 42:50

It is all on the record. Their physician advisor is going 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 for the highest mark, because that's what we had to do in order to try to get here. And all of a sudden, you know our uh, the cleveland clinic learner college of medicine doesn't have grades. We have feedback only, um, as is how we're graded, and um, that that in itself is an adjustment to begin with, but that's really how the real world works, right? We don't, you know, spend our year working as a neurologist and at the end be like, okay, you got an A this year, good job. Or you got a B, do better next year, right. It's like, okay, here's what you did effectively and here's what we can work on for next year, so that that in itself is a, a transition, um within the peer to peer format. Um, I think we.

Chris Cantrell: 43:52

I think we improved both in the giving and receiving of feedback, which I think are two very different things. So, in the giving of feedback, picking actionable feedback, that at that level, you don't go too crazy with it, right, you just say you can work on your time management in your 15- 15 minute presentations or maybe you can do better eye contact next time, right? Just the kind of soft feedback that you can, that you can improve on but that you can really show improvement in, based on you know future feedback forms and that's kind of a longitudinal structure of you're getting feedback from your peers over, uh, like a whole whole. You present that and you write up a portfolio, as we call it, sort of a long essay, using your evidence that you've gotten your feedback to prove that you both are competent in what we're supposed to be able to do in terms of the med school requirements and that we've improved. So it's an improvement mindset. And then when you get more into the peer like older peer to younger peer I think you see that evolve in terms of.

Chris Cantrell: 45:04

So when I was working as a CS communication skills preceptor, I had the opportunity to give a lot more feedback to younger students and in that, having been in their shoes recently, I felt like I could give them more targeted feedback towards like here's what I wish I had known then. Or here's something that I've been doing that I wasn't doing when I was at your stage, but that really helped me take the next step. So I think it gets a little bit less like I'm worried about, you know, hurting their feelings or them not liking me as a friend anymore, and a little bit more like here's something that can really help you, because it helped me. Like two years ago or one year ago I didn't really feel like a power dynamic.

Chris Cantrell: 45:46

I guess, you know, authority is probably not the right word, but I felt like they would listen more to what I was saying in terms of advice for how to change, 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 job Maybe, maybe maybe more eye contact. It's a little. It's a little bit different at that level.

Dr. Michael Kentris: 46:13

Right, right. So feedback, obviously you haven't been in the position where you're the attending or the senior resident on service providing feedback to trainees, so that does provide. I would say that power dynamic does shift a little bit as you move more into this. For better or worse, it's the way, the way it's structured, this hierarchical, uh kind of system, and so you know, you do try, it's one of those things and I find that I have to to balance this myself. Also, you know, because I have to 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 them to gain in terms of skills and experiences and so on?

Dr. Michael Kentris: 47:04

And so it's particularly challenging, I think, for for medical students, right, because you don't want to like write some some kind kind of uh review that could be considered as like scathing or things like that. So I usually do try to do more informal, verbal feedback rather than writing like a long thing Like, hey, you know, your, your assessments were, were pretty weak, uh, despite our talking about them, and you didn't really, you know, flesh out your thought process, blah, blah, blah. Right, it's like these things that that we kind of hope that people are getting better at over the course of a few weeks. Um, and you know you don't want to just write the, the ubiquitous uh. Read more in terms of your student feedback either, right? So so, from your perspective on the receiving end, uh, on clinical rotations and things like that, what do you think has been the most useful way of getting feedback, whether, like in the moment, at the end of the rotation, in your written um written assessments or what have you?

Chris Cantrell: 48:09

yeah. So I think there's um. Know, I guess part of it depends on how long your rotation is. So let's imagine we have a one week rotation, right, and then we're you know, and then you're attending changes every week or whatever it is. I found it most helpful to have kind of a midpoint verbal feedback and so you can assess okay, how am I doing what, what's working effectively, what could I work on in these last couple days? And then the endpoints. So whenever that attending or your senior resident or whoever you're working most closely with, is switching off service, saying okay, here's how we've grown since then, and kind of just overarching feedback.

Chris Cantrell: 48:50

I think written feedback can certainly be helpful. It's easier to go back and look at and review later on because it's it's always there, um. But for me it's those kind of verbal, kind of candid, just conversations about, okay, how did things go? Um, it can be more comfortable. That way you have a chance to respond as well. Written feedback is just kind of it. They write it down and then it's just out there. You't have a chance really to say, okay, well, this is what I was trying to do or, in this situation, here's, here's what I was thinking, or just to acknowledge like, yeah, I think I could do better on that and, and I think acknowledging that you have room to grow is also a strength and uh reflects well on you, um, as a as a lifelong learner. As people like to say yes, but yeah, I think for me it's been the verbal feedback that's the most helpful and some of the most memorable kind of formative experiences.

Dr. Michael Kentris: 49:42

And I think it's important to emphasize.

Dr. Michael Kentris: 49:44

You know there are some rotations where that will be more structured, where the attending is kind of built into the rotation almost. But there are many rotations where you know the attending is of built into the rotation almost, but there are many rotations where you know the attending is busy, maybe they're understaffed. You know, I'm sure that never happens in medicine anywhere, but if it is entirely possible they will forget to give you feedback. So I think, as a student or a trainee, it is important to seek that out as well. If you really have a genuine interest in improving yourself and I would say, doubly important if, say, you know you're applying to that self-same specialty, you want to try and get a letter of recommendation, you really need to be kind of going after that uh and being uh, what they might call in the business world managing up a little bit, little bit in terms of like, hey, you know, dr, so-and-so, I really like your opinion on how I'm doing on this rotation and what I can do to really, you know, perform well by the end of this rotation, because I'm thinking of applying to the specialty and you know so on. But it is, it is important to set those expectations early in the rotation, because if you want a letter of recommendation, you're only with this person for one week and they didn't see you that much and your performance was a little mediocre. They're not going to write you a great letter of recommendation, that's for sure. And so you definitely need to make sure that you're doing what you can to put your best foot forward. You're doing what you can to put your best foot forward and again right Kind of comes to that communication aspect of things where you're telling them like hey, I'm interested, I want to apply to this and I would like to do well enough on this rotation to get a letter of recommendation from you. So what do I need to do to do that? And then, executing on that midpoint, find out like am I, am I heading in the right direction? And hopefully, by the end of that period together, you've done well enough that you've, you know, demonstrated, you know improvement, or you know whether or not you're like.

Dr. Michael Kentris: 51:45

There's always like subspecialties where it's going to be really hard to like, be like really impressive. But it's the expectation of what do I expect from a third year or a fourth year medical student versus what do I expect from a third or a fourth year resident, right? It's entirely different skill sets, so. So I think it's really important because I'll I'll sometimes get requests for like letters of recommendation, like near the end of the rotation. I'm just like you know I can write one, but you know it's not going to be great and I hate saying that, but it's, it's the truth, right? Um, yeah, so so it's.

Dr. Michael Kentris: 52:21

It is important to make sure that you're like really excelling, right, you want those, especially with residency applications being the way they are these days. Um, you want to do everything you can to like get a really stellar letter, and just having those conversations, I think is a big. It will dramatically increase your chances. As far as, as that piece of things go, I don't know what's your better, your experience as someone more recent, uh, as someone who went through ais in the last three months uh, yes, months, yes, very recent takes.

Chris Cantrell: 52:53

I, yeah, it's it, it is. It is hard to open those conversations at times. It's easier with the residents, especially those that you're working closely with. I would often seek feedback from them, kind of at midpoint, and, uh, you know the uh. My favorite question is is there anything I can do to be helpful right now? Um, just throwing those things out there into the wind to be like I'm looking for ways to be helpful and then, when getting feedback, making it a priority to whatever that thing is of.

Chris Cantrell: 53:23

I want to see you work on your differential diagnosis. I want to see you going to check on your patients by yourself in the afternoon and just giving them updates, whatever it is. Patience by yourself in the afternoon and just giving them updates, whatever it is. Doing those things is going to make you look the most impressive. Beyond just starting good and ending good because it's like, okay, this person wants to improve, and someone who wants to improve is someone who's going to work hard, who's going to be a good team player. I think that reflects even stronger than just being good alone for me personally, as a person who is constantly trying to improve because there's room to um and when with the attending.

Chris Cantrell: 54:01

Sometimes it's hard, sometimes you 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're insanely busy and they've got a team of, you know, eight residents and one medical student and they're trying to talk to everybody, right, um. So it can be hard. But catching those moments where it's like, okay, now is my time, like it. Just it hits in your brain of like, okay, I've got a chance here. Just asking do you have any feedback? And from what I've heard from you know attendings that I'm close, they love hearing, that, they love giving feedback, they love people who want to get better and, uh, um and to to kind of help in that process. And it doesn't even have to be a long conversation. You just edit or two and that can make a big difference.

Dr. Michael Kentris: 54:44

Right, and I do think again, right, this is, this is my perspective. You know I'm not currently at a neurology training program, but when we would have medical students who were there on a sub-I rotation or audition rotation or even just third years who were interested in neurology or considering it, it's like you get brought into the inner fold almost immediately. So it's a double-edged sword. Right, you will get the attention if they know that you're interested in neurology, but the expectations go up immediately. So they're going to expect you to be doing a lot more. But you will get that attention and that personalized touch if you're able to kind of meet those expectations. I kind of think of it. It's like you know, joining a cult, right, it's like, hey, I'm interested in joining your cult. Like, oh, really, let me tell you about, about the good news yes, yes, uh.

Dr. Michael Kentris: 55:46

So here's what you have to do. Here's your, here's your hammer and here's your tuning fork. So, so, uh, but it it really is true, like you know, if I I've worked with a number of medical students, even where I am now, and as soon as they say they're interested in neurology, I'm like, all right, let's, let's talk about that. And, uh, what we need to do to, you know, get your best foot forward and get all those things kind of lined up over the next year and kind of right, it's a small, it's a small community. You know putting you in touch with, with people at local institutions and you know getting all those things moving that are going to give them the best chance to to get into a program if they want to. And I don't know, has that been your experience as well? Like when you've expressed that you were like, oh, I'm interested in applying to neurology.

Dr. Michael Kentris: 56:38

Yeah, I think you definitely get more uh direct attention, as opposed to my surgery rotation, where I said I was interested in neurology and the opposite happened, which is right you like fade into the wallpaper which you know I didn't mind too much but no, it was.

Chris Cantrell: 56:44

It was good. There was a lot of no. I learned a lot through through that rotation as well. But the uh, I'd say, on my neurology rotations you could definitely see the expectations go up, but not in terms of necessarily of being correct all the time, which I think is a common, just sort of instinctual assumption that medical students or people who are being evaluated, yeah, think that they have to be right all the time, and it's depressing when you're not and, uh, I think it's hard to get away from that.

Chris Cantrell: 57:15

But having you know it's, it's more about showing the that you want to learn, that you want to be part of that kind of team that you're comfortable working with, kind of the elements of that specialty and then your patient care and how, how much your patients respond to you and, like you within the, you know the confines of their personality and you know and and and all that. But that that's what stuck out to me the most. But it wasn't when expectations went up. It wasn't expectations that I know everything, it was that expectations that I would want to learn things, that somebody on that rotation who wasn't interested in neurology would not be interested in.

Dr. Michael Kentris: 57:56

Right, and that's you know. Same. Similarly, from from the attending to the trainee side of things, it is important to set those expectations Like what do I expect for for a third year student, for a fourth year student, for someone on a sub I? For a junior resident, a senior resident student, for someone on a sub-I? For a junior resident, a senior resident, right? These are all different skill sets that people should have mastered as they go up the ladder and saying like, or I should say, for rotating residents, right? So for people who are coming from internal medicine or family medicine or emergency medicine onto the neurology service, the expectations are different. They'll have different skill sets that they're bringing to the table.

Dr. Michael Kentris: 58:32

A lot of times I say and this is right, if you already knew everything that you needed to know to practice neurology, well, there wouldn't be much point in the training, would there? And I think, right to your point, reassuring people that this is in fact the case. What do I expect? I expect you to be able to talk to the patient, gather a story, put the story together in a comprehensive and coherent way and then create a differential diagnosis, right? I don't know that you need to have the correct diagnosis you want.

Dr. Michael Kentris: 59:04

There's a lot of weird stuff in neurology, you know. Sometimes I got to do some reading too. But the point is like, hey, let's engage in the thinking exercises that go along with the practice of neurology. Right, the localization and the timeline and kind of putting together an appropriate list of possibilities and engaging in that thought exercise more than anything, right, I just want to know can you think that's really what I want to see, right? Can you talk to the patient, get the information and think about it, and think about things that make sense? Not everything is a stroke, not everything is a seizure. There's other stuff out there. Let's think about that. So I think that's the most useful part of neurology. I'm probably painting with too broad of a brush, but I think that gets lost a lot in other specialties, but in neurology we're so dependent on it, that information, that we can't. Even if we wanted to, we couldn't get away from it because we would just be bad at our jobs.

Chris Cantrell: 1:00:08

Yeah, I think that's totally true. And in terms of when you evolve from 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 work like a neurologist and do you want to right? Like, will you put in the teamwork? Will you work? You know, improve documentation? Will you, you know, take care of your patients and you know, review their charts and catch, okay, maybe we should have them on this medication or that. Um, you know, and all those things don't necessarily have to happen, but are you looking for it? And then you know, is, are you at that level of, okay, this person could be an intern in our institution and and be successful?

Dr. Michael Kentris: 1:00:48

Right, and. And so since you said the magic words, uh, there is a great book out there called how to Think Like a Neurologist that I do recommend. I actually interviewed the author on a past it's almost been two years ago, I think now Dr Ethan Meltzer, but very good book and it's just exactly what it says on the tin. So you kind of walk through and each one is a little case and they're like let's think about this what's the localization, what's the time course, what's the syndrome, et cetera, et cetera. And it's exactly that Like how do we, you know, train our minds to think like a classical neurologist, different than how an internist usually approaches a neurologic problem, or an emergency physician or a family physician? And I think it's good to have this different way of thinking, because the way that we tend to create our differential diagnoses is, I think, a little unique as far as that goes. But just because the nervous system is what it is right. But I think it's a very interesting thought experiment to engage in and when you're first starting out like I wish I had had that book when I was a junior resident, it was very helpful and something that I just 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 in terms of crystallizing how I right again we're talking about communication for those who forgot as we were rambling, but the kind of the transmission of information.

Dr. Michael Kentris: 1:02:24

So for me as an instructor to my students, like, why do I think this? You know, it's not just like gestalt, I mean sometimes it is, but we need to try and put those gestalts into words and have reasoning and a rationale behind what we do. And I mean it's too often that we'll see like, oh, why did they put you on this medication? Why did they do X, y or Z? It's like, oh, that's just I don't know, that's just what they did. And you don't find anything in the documentation, you don't find any reason for something. And it I'm always torn between my twin desires like I shouldn't say desires, but my twin thoughts of like there must be a reason for why this person did this, versus that seems like a really stupid thing to have done, right. So I just kind of ping pong back and forth and I'm just, like you, kind of have to remind yourself like these are also medical professionals. There may have been a piece of information that I don't have that justifies what they were doing at that time. Right, yeah, um, so it's. It's always easy to take the easy way out and say like that's dumb, they shouldn't have done that right. But in reality there may have been a reason, I just don't know it, and so that's always the hard part.

Dr. Michael Kentris: 1:03:43

So I think also to kind of tie in our third piece of communication is like the medical record itself and these paper charts, and not necessarily the focus of our conversation today. But I think charting is somewhat important, although we all hate it because of the burden that insurance has put on us. But I think it's important to document what you're thinking and why you're thinking it and what you intend to do about it. Everything else is window dressing, more or less, but if you can at least document that.

Dr. Michael Kentris: 1:04:18

So someone picks up your notes like, oh, you know, dr Cantrell, he thinks this person has you know whatever, you know migraines and they're trying this medication and they're going to see him back in two months and see if it's working or not. And it's like, oh, I know everything I need to know about this particular problem that they're dealing with and that's really kind of important right. It's like if we just do kind of shoddy notes and they don't explain our thought process, there will be a doctor who comes along and says like oh, that guy, he doesn't know what the heck he's talking about, he's just, you know, he's just throwing darts at the wall and so you don't want to be that doctor, or at the very least you shouldn't be perceived as that doctor because of poor documentation. You should at the very least say like why you're doing something and what you think it is. It doesn't necessarily need to be, you know, a three-page essay, although certainly in your clinical experience, those POTS patients, sometimes the histories are quite extensive.

Chris Cantrell: 1:05:20

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

Dr. Michael Kentris: 1:05:21

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

Chris Cantrell: 1:05:32

Yes.

Dr. Michael Kentris: 1:05:34

But yeah, so that's kind of my perspective, but it's that third way of communicating. Very often we're communicating asynchronously and remotely to our other colleagues. Medicine is so fragmented that we may not be getting on the phone and talking to them. If our documentation can communicate what we're thinking to them, that can be almost as good is good.

Chris Cantrell: 1:06:02

Yeah, no, that's I usually when I'm writing notes and obviously I'm still early on in the in the stages here. But uh, I I usually at least for assessment and plan or, you know, hpi, those kind of narrative sections. Uh, I think of, like, if you're talking to, like, if you're presenting it to a doctor you don't know, right, just any any one individual, just to, to lower the pressure on yourself just one one individual that you don't know so that they can look at it. That's just imagine you're talking it to them. Um, I know some people like to dictate I'm more of a typer than a talker out loud but, um, I think that can kind of help keep it uh, uh, kind of conversational and easy to read as well. Yeah, um, easy to read and comprehend.

Dr. Michael Kentris: 1:06:40

I always think. Again, I can't place the quote and this is more of a paraphrase than anything, but I'll sometimes get asked by students or residents like how long should my note be, or how long should my HPI or my assessment be? 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 give tongue-in-cheek answers most of the time. But uh, I'll say it, it should be as long as it needs to be and no longer so it's good advice.

Dr. Michael Kentris: 1:07:10

But I mean, it's true, right, we've all read the notes that are, you know, like literally one sentence and just like I don't know what, what the heck is happening here. And then, on the complete opposite end of the spectrum, there's this long winding note full of extraneous information. It's not in a chronological order, right, it's a narrative disaster. And so you spend so much time, right, it's probably exactly what the patient said in the visit, in the visit, but you as the provider, as the physician or the APP or whomever, need to translate that information into something so that when it lands on somebody else's desk or when they come back to see you in like three, six months or whatever, you're not having to spend 20 minutes reading these records that maybe you yourself wrote to yourself to figure out what.

Dr. Michael Kentris: 1:08:02

What was I thinking, you know, a few months ago? So be kind to your future self, be kind to your colleagues, I would say. Is that on that front? So any final thoughts about communication. If, in your experience, you know, seeing, you know, obviously you've got your experiences at Cleveland Clinic, working with, perhaps, students from other training programs or residents who came from other training backgrounds, I know communication training like this is not necessarily universal. It's certainly gaining popularity in a lot of places. Um, what's your kind of, your, your bird's eye view? Again, just anecdotally about communication, training in medicine and uh, where it stands for, 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 of improvement in our practice at present?

Chris Cantrell: 1:08:58

Sure, no, I. I think that, for first of all, I loved communication skills as a first and second year medical student. It was, I think, one of the highlights, both because, um, I enjoyed the practice of getting better at communicating in general and, uh, my first year and like half a second year of medical school was, uh, during the COVID pandemic, so that was one of the few times we got to come 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 communicate one way. It's not. We're not turning, you know, we're not teaching them all to be the same physician. It's more so, we're providing them with like a toolkit and they can choose which of those tools they want to use and how they want to use them within their own unique style. So, in more of a way, it's more so teaching med students how to be themselves with patients, and that's the way that I look at it and the feedback that I gave was mostly targeted towards okay, this is, you know, you have these strengths as a person, use them and then take these other things.

Chris Cantrell: 1:10:09

That I took away from it and tried to teach to my students was the practice of self-reflection. We've talked a lot about talking to other people. How do we talk to ourselves? Good point, and that is really hard because the very first day you do your standardized patient encounter and then someone you know three of your friends are sitting there looking at you and a couple preceptors looking at you, 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't like how I did this, my eye contact was bad, like that. That's where our minds go, just naturally, because we're like we focus on what we didn't do well, that perfectionist mindset. Um, and so that's the.

Chris Cantrell: 1:11:00

The hardest thing is to teach these students, and it was hard for me to learn myself. To start with, what we call reinforcing feedback. Try to stay away from positive and negative reinforcing feedback. Here's what I think worked effectively for me. I think that my eye contact is improved. I think that I really built rapport with this patient by talking about, you know, this aspect of their family life they brought up.

Chris Cantrell: 1:11:23

And then here's what I would work on next time or what I could have done differently. You know, next time I want to work on thing X thing, y, whatever it is, and those that has become a common practice for me. Every patient experience that I have is now an opportunity for self-reflection. I think I did these things effectively. I think next time I would want to work on that.

Chris Cantrell: 1:11:44

And just another kind of corollary to that is I try to stay away during self-reflection from the word should as much as possible, because immediately I should have done this, I should have done that. We're kind of assigning blame to ourselves for something that we perceive we should have been doing, as opposed to well, I could have done this differently. Maybe next time I can try that and see if it'll work better for me. Um, and that I feel like it's you know, it's, it's all mindset, it's all practice, it's whatever works best for you. But that self-reflection component has you know, beyond even the uh, learning how to communicate with others. It's helped me beyond medicine, beyond talking with patients and peers, but just in my personal day-to-day life.

Dr. Michael Kentris: 1:12:25

Now, those are great points. That negative self-talk is, I think, definitely something that most people in medicine struggle 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, it doesn't help, right, it doesn't. It doesn't make you feel better, it doesn't make your performance better.

Dr. Michael Kentris: 1:12:50

So it is very useful and challenging to kind of reframe those things and I I kind of hate this. Right, it's become like a bit of bit of corporate speak right. These I kind of hate this. Right, it's become like a bit of corporate speak right. These opportunities for improvement, quote unquote. But in reality, I mean, when you'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 for growth. Different context, but it really is true, right, we do have these opportunities and you know, it's perhaps gotten a bit of a bad rap due to online discourse, but having this growth mindset, which ties into being that lifelong learner, looking to constantly improve our skills, really important things, and it's very easy for us to kind of dismiss these again, like, as we said, kind of near the beginning, these, these soft skills as something. But I've known so many physicians where you know outside of the clinical setting they're super nice, super friendly, but then you get them in, like to a patient encounter, and they are all stiff and rigid and kind of sweaty and nothing against sweaty people, but I am at times amongst them. But it is one of those things where it's like dude, what's going on? These people, their entire demeanor changes and it goes back to what you were saying, that they are not being themselves. And it is one of those things where that self-talk you have to be first Okay With being yourself, um, to be yourself in front of somebody else, especially when you're you know you're engaging with someone in a vulnerable position. Right, there's a sharing of information and you know, sometimes you're sharing different experiences. Some of those may be quite vulnerable in nature depending on the conversation and it. You know, if you're not comfortable with yourself, you're not going to be comfortable having these conversations.

Dr. Michael Kentris: 1:14:58

And I think something we all struggle with when we first enter clinical practice. In particular, you know we're asking about things like sexual history, you know. You know illicit drug use things like this, things that are not considered a polite conversation, quote unquote. And so you're kind of moving into this different realm of what is socially acceptable, right You're. You're assuming this mantle of a healthcare provider and, to an extent, right, if I'm walking through the grocery store I'm not asking, you know, the random lady in the produce aisle like, oh hey, how many packs of cigarettes a day do you smoke? Or you know, have you ever had hepatitis? Or you know all these things that in a clinical setting would be entirely within the realm of conversation.

Dr. Michael Kentris: 1:15:44

So it's this reframing of like, what is it okay for me to, to do and to ask in this setting versus my normal social interactions, and that that does have a steep learning curve and some people struggle with that, that transition quite a lot, I know I I did the first couple of years that I was, that I was in clinical years in med school and as an intern. But ultimately, right, you got to have these conversations. So you just kind of got to tear the 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.

Dr. Michael Kentris: 1:16:22

It's one of these things where it's a weird social phenomenon where we're expected to quote, unquote, be ourselves but we also have to be, you know, the face of their health care administration, and so you kind of have to be yourself but also be something else at the same time. It's this weird superimposition of these different social roles, so it can be hard, especially if you're, like I said, not comfortable with kind of who you are. I don't know, I got kind of metaphysical there for a second. What are your thoughts about all that?

Chris Cantrell: 1:16:58

I love it. I think that's really where the communication skills course helped me was. You know, if you're, it's almost like you're performing in a way at first right, you're pretending to be a doctor, you're pretending to be a medical student who feels like they're part of the care team. That was my growth journey. In the first you know, year or two, uh was realizing, okay, I am part of the care team, the questions I'm asking can matter, um, and I'm not just inconveniencing this patient by talking to them before the doctor does um, but but kind of realizing what, what's holding you back, what is stopping you from being yourself and that doctor at the same time, right, and uh, doing that in front of uh, sort of like in a, a environment that's established to be like a, like a safe learning environment, you can do anything, you can say anything and we're just going to give you feedback and grow all together.

Chris Cantrell: 1:17:56

That was, that was huge and it almost like, in a way, when I was alone with patients, I felt more comfortable. Like it made being alone with patients 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're putting all this pressure on yourself. That's really you doing it to yourself. 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, was one of the biggest things, was, uh, was finding myself as as a communicator, um, and being able to be, you know, just the way I'm talking to you now is the same way I talk to patients. You know, and we joke around when appropriate and and you know, and and laugh and comment on things and and feel like, uh, like what we're saying is is important to them, right, that's that's what it, that's what it has to be, that that's exactly right and that's that's actually one of the pieces of feedback I've given.

Dr. Michael Kentris: 1:18:51

Perhaps again, I can't keep from joking it's. It's perhaps to the point of a personality flaw, but uh, it's like. You know, just talk to people like they're people, right. You know, don't turn into like a lizard person when you're in a patient encounter. You know, like you've forgotten what do humans do during normal social situations. And again, I know there are people who are like kind of on autism spectrum and things like that, that will struggle more with some of those social cues and things like that cues and things like that. But when someone is acting normally outside of the room and then their whole demeanor changes, that's more what I'm kind of intimating at, and it is one of those things where you just talk to them like you would talk to anybody else and that's going to solve a lot of your problems, I think.

Dr. Michael Kentris: 1:19:40

For anyone out there who's kind of struggling with that, I kind of think back to um, you know kind of like classical, like ethics. You know the big question what does it mean to be a good person? And it's like, well, what does a good person. Do you know? They like, they care, take care of their family, they are responsible members of the community, blah, blah, blah. Uh, the rest of the details. But you do the things that a good person does. Does that mean that I am good? It's the same thing for becoming a physician. I do the things that a good physician does. Am I a good physician? I don't know. But at some point it's not just the things that you are doing. I've been reading too much metaphysics lately, but it's like the doing leads into becoming right. So by doing the thing it's kind of the fancy version of fake it till you make it right, but you're not faking it, you are doing it right, you are doing the thing. And so by doing the thing, eventually you I heard this said if you want to be the noun, you have to do the verb, and I really liked that a little more you know right. So if I'm, if I'm doctoring, eventually I become the doctor. So, and it's one of those things where you kind of you accumulate these skills over time.

Dr. Michael Kentris: 1:20:57

And you know, communication, as we've said, is one of these very fundamental skills, so fundamental it's almost overlooked in some arenas and I think it's one of those things where we spend so much time learning about physiology and anatomy and pharmacology and the litany goes on forever. Neglect this, this beginning point, right? Uh, if we don't talk to the patients, if we don't tell them like, hey, we're doing this because of this, then you know all of it's just so much wasted energy. You know, we, we did the tests, we make the recommendations, the plan falls apart because we didn't communicate it. Um, so anyway, uh, I, I am diverging significantly, but I just find it a very interesting phenomenon, you know, in the course of like language and thought and all these kinds of things that are wrapped up in like the underpinnings of communication.

Chris Cantrell: 1:21:56

I think, you know, communications become almost even a kind of a passion of mine within the context of education and even just myself, self-reflection, can I improve how? You know, how are the things that I say perceived by others, and how does that help or hurt me in my goal to to help them, and you know it's a it's a constant day by day journey. We're going to keep on, keep on doing it on my end and I hope medical students out there keep on learning as well and keep improving too.

Dr. Michael Kentris: 1:22:30

Yeah, uh, what's that? Uh, there was a Pink Floyd song, I think, out there. It was like uh, just keep talking from one of their less popular albums, but that's okay. Uh, it's a good song, but but that's the point, right? It is just keep talking, right, even if you're not good at it to begin with. Keep practice, just like anything. 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 a great point to end on is just just keep talking, just keep communicating, just keep working at it.

Chris Cantrell: 1:22:55

I love that.

Dr. Michael Kentris: 1:22:57

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

Chris Cantrell: 1:23:05

We've got POTS research out there. Search for Dr Robert Wilson and you'll find some of our POTS work, found some interesting things related to post-COVID syndrome and POTS and a number of other things. Low-dose naltrexone we've been working on as potential therapy, and then, yeah, feel free to reach out. My email is c a n t r e c at ccforg, and you know. Appreciate you, dr Kentris, for giving me the chance to talk about this today.

Dr. Michael Kentris: 1:23:35

No, this is a really fun conversation. I appreciate you taking the time, especially as we go into interview season. I know how busy that gets for people. I appreciate you taking the time, especially as we go into interview season. I know how busy that gets for people. And you can, of course, find me online. Our website is theneurotransmitterscom, and you can find me mostly on X, formerly known as Twitter, at D-R Kentris, k-e-n-t-r-i-s, and you can always email us from the website as well. Chris, thanks again. I really appreciate it and good luck with all the research.

Chris Cantrell: 1:24:05

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