Michelle Kittleson MD PhD @MKIttlesonMD
#kittlesonrules | Cardiologist | Prof of Medicine @CedarsSinai | Author Mastering the Art of Patient Care available at https://t.co/zdJT2MVNhb bio.cedars-sinai.org/kittlesonm/ind… Los Angeles, CA Joined November 2018-
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#TipsForNewDocs Don't shy away from giving patients bad news- false hope is worse. Offer honest assessment of prognosis + options -> together make a plan. End with a promise: you will still be their doc even if you can't fix their disease. #kittlesonrules
#TipsForNewDocs There are some essential meds in cardiology. HFrEF: ARNI/BB/MRA/SLGT2i. CAD: aspirin/statin. If a pt isn’t on the first-line meds, document why. Clear notes: you look good + others don’t have to reinvent the wheel= win-win! #kittlesonrules
#TipsForNewDocs: Art of the consult: 1) call early in the morning (consultants have lives too) 2) try to have a specific question: not “pt is anemic” but rather “anemia, low retic, no fecal occult blood, norm Fe/B12/folate —> do we need bone marrow bx?” #kittlesonrules
#TipsForNewDocs Sinus tachycardia is the delirium of cardiology. Delirium --> it's (basically) never the brain's fault. Sinus tach --> it's (basically) never the heart's fault. Don't be distracted by the wrong organ in search of the right answer! #kittlesonrules
Sometimes I’m asked how I “do it all“ w/3 kids and a career. I don’t. Career extras like research get put on hold when family requires more attention. Life happens in stages- don’t be hard on yourself. You’re not supposed to accomplish it all at once. #kittlesonrules
#TipsForNewAttendings Sometimes you can tell a trainee doesn't agree w/your plan but isn't sure what to say. Encourage questions and debate. You'll model respectful disagreement and explaining your rationale --> better understanding for you and the trainee. #kittlesonrules
#TipsForNewDocs Inpatient has renal mass on u/s. Plan is outpatient eval. No: "Defer to outpatient." Yes: "Per discussion w/rads, renal cell ca possible. Pt ready for discharge today; PMD aware, renal CT scheduled.” Don’t leave loose ends hanging. #kittlesonrules
#TipsForNewDocs It's great to titrate up meds on inpatients, but before you do, check the medication administration record (MAR) to ensure pt rec'd prior ordered dose first. Just b/c you order a med doesn't mean the pt received it-- trust the MAR! #kittlesonrules
76F has lipid panel: cholesterol 254, HDL 89, LDL 145, triglycerides 92. ASCVD 10-year risk 21.5%. Also needs MV repair for MVP with severe MR so CTCA ordered: no evidence of coronary artery disease and coronary artery calcium score zero. What do you recommend?
#TipsForNewDocs Complicated pt came to see me (cardiology). GI: get abd CT w/contrast. Nephro: don’t get abd CT w/contrast. Pt: ??? So I messaged GI/nephro for her. Talk to your colleagues! Avoid relaying medical recommendations through the pt. #kittlesonrules
#TipsForNewDocs The practice of medicine gets better (more rewarding, less scary) with experience. Approach medicine like a foreign language- put in the effort to memorize the grammar and vocabulary and you will soon be able to appreciate the poetry. #kittlesonrules
#TipsForNewDocs If the only justification you can muster for ordering a test is "the results would be of academic interest” or “I just want to know,” then don't order the test. #kittlesonrules
#TipsForNewDocs Bad: See the cardiologist for an angiogram. Good: See the cardiologist to decide the next best step for your symptoms. Don't paint the consultant into a corner- allow them to use their expertise to chart the right course for the patient! #kittlesonrules
#TipsForNewDocs You’re never too important to look it up. I’m a cardiologist and I still look up the treatment of pericarditis. I don't treat it a lot and want to ensure I have the duration/taper of NSAIDs right. UpToDate = your friend for life. #kittlesonrules
A patient transplanted as a child establishes care in your adult program- no complications or concerns. A few weeks later, his mom requests a phone call with you, without her son, because she was not at his visit. He gives permission to talk with her. What do you do?
#TipsForNewDocs Cringe-worthy chart phrases: “Avoid nephrotoxins” (w/o adding relevant ones) “Lungs clear. No crackles.” (redundant) “Pt has leg swelling x3d”… exam: “no edema.” (inconsistent) “Consider XYZ” (w/o saying why or why not) #kittlesonrules
A patient with whom you had a very close relationship but haven't seen in 5 years calls your office. He doesn't want to schedule an appointment, telehealth or in clinic, but requests that you call him to discuss recent health concerns. What do you do?
#TipsForNewDocs There’s a right time for negative/constructive feedback, but there’s never a wrong time for positive feedback. Give credit where credit is due: appreciate trainees, referring physicians, nurses, and ancillary staff early and often. #kittlesonrules
A patient sees your colleague for cardiac evaluation, then requests to switch their care to you because you have more experience. You review your colleague's management which is appropriate and know that your experience/expertise are not warranted. What do you do?
#TipsForNewDocs Taking a social history: Bad: no smoking or alcohol Good: born/raised, job, lives with, kids/grandkids, smoking, alcohol, drugs Learn the details that make your patient a person - getting to know them = providing better care. #kittlesonrules
Andrew J Sauer MD @AndrewJSauer
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@MKIttlesonMD Dr Kittleson, what's your opinion about the REDUCE-AMI trial? Is it safe now to forego BB in these patients? (asking as a GP)
@MKIttlesonMD If patient can't tolerate 1st line meds, document why they cant.
Life isn’t fair, but that doesn’t mean the #UNOS 🫀#transplant allocation system shouldn’t be. @shelleyhallmd joins us @nyulangone bit.ly/NYUAHF24 Free for ALL trainees Code: 21824resifellow 50% off for attendings Code: 21824local #HFSA #ACC24 #ISHLT2024
⏳early registration for #ISA2024 ending soon. Virtual & in person, state of the art #amyloidosis Amyloidosis_ARC @AmyloidosisSupp @MayoAmyloid @BU_Amyloidosis @Amyloid_MUSC @MayoClinicCV @MKIttlesonMD @BrettSperryMD @MasriAhmadMD @maz_hanna cveducation.mayo.edu/store/internat…
Congrats @Richardkcheng2 @MKIttlesonMD et al on this @AHAScience Statement on Cardiac Sarcoidosis! ahajournals.org/doi/10.1161/CI…
📌Right on the heels of #IM2024, I'm excited to share this article: “Not Superheroes: Holding Space for Physicians to Grieve” published on the @AnnalsofIM Fresh Look Blog as an @ACPIMPhysicians volunteer. 📌5-minute read; perfect for a busy Monday❗️ 🔗:freshlook.annals.org/2024/04/not-su…
🧵 2/2 @MKIttlesonMD The show notes are also excellent providing very helpful references for further reading and understanding. I look forward to your final episode for this season and upcoming episodes in Season 3!
🧵 1/2 @MKIttlesonMD, your In discussion: Heart Failure podcast series on Medscape goes from strength to strength! Great work on selecting very relevant topics and covering them so well with your engaging discussions with guest colleagues.
Only fitting during #sarcoidosis Awareness Month our first presentation on rounds today is a cardiac #sarcoidosis patient. And that #Osler teaching included the hot-off-the-press @AHAScience Guidelines Statement on Sarcoidosis Diagnosis and Treatment by none other than…
@MKIttlesonMD @hmkyale And start with the punchline! Unless it’s a mystery case presented at morning report, the call will be much more productive if leading with “I’d like to discuss disposition for a patient with suspected pericarditis” than a bland chronological presentation
Update your consultants not just because you have to, not just to finish your job... Update [early] so you know what needs to be done for/to the patient. Patient pa din. 😉
#TipsForNewDocs: Art of the consult: 1) call early in the morning (consultants have lives too) 2) try to have a specific question: not “pt is anemic” but rather “anemia, low retic, no fecal occult blood, norm Fe/B12/folate —> do we need bone marrow bx?” #kittlesonrules
@MKIttlesonMD dying art, losing battle. proliferation of HCA and non academic residencies has destroyed the true IM inpt training model and practice. now consults placed via EPIC anytime of day with no phone call, leading to bs consults, wasted time, inc cost, incompetency
@MKIttlesonMD Also pro tip: please don't order fecal occult 😂
@MKIttlesonMD I always tried to understand the 4:30 pm consult for a patient that had lab at 6am (no repeat) and a note at 10:30 am by primary service. Never have solved this conundrum.
@MKIttlesonMD And in South Asia, stool negative for hook worm ankylostoma duodenale
@MKIttlesonMD When I was an IM resident in another century we couldn’t ask for a consult unless it was for a procedure.
@MKIttlesonMD This advice also applies to “old” physicians
@MKIttlesonMD @VietHeartPA Correlary: don't be upset when the consultant asks you questions. We're trying to understand how best to answer your question effectively. It's not pushback