The Patient Connection

Craig S. Kitchens, MD
Professor Emeritus of Medicine, Department of Hematology & Oncology, University of Florida

What qualities make a good mentor?

To me, mentoring and teaching are essentially two sides of the same coin: One cannot teach well without mentoring well and one certainly cannot mentor well without teaching well. So, a good mentor is a good teacher.

Personally, I admire physicians who are loquacious and who speak from their heart when speaking with students, sick patients, or their families. They are straight-shooters – if the patient has a poor prognosis, they don’t talk around or dodge the issue. Patients, like all of us, want honesty, whether it’s regarding a pulmonary embolism or a tubal ligation. People want to know what you’re doing and why you’re doing it.

As a house officer, I had the opportunity to work with some of the best professors in the world and, if there is one thing I would pass on to my trainees, it would be to not waste precious opportunities. I would sit down for coffee with one of these brilliant minds and ask them, point-blank, “You’re recognized as an authority in medicine – how did you get smart?”

No matter the field they were in, they offered strikingly similar advice: work hard and pick great role models. If one of my trainees asked me that question, I’d give them the same answer. When you’re listening to your professors talk, find out what you like about their style (their bedside manner, their knowledge, how they handle difficult patients), and emulate that. Keep doing that, and by the end of your medical training, you’ll have a decent collection of traits to build your style.

How do you teach professionalism to your trainees and mentees?

Professionalism is a necessity. From my viewpoint, as a member of a consultative team such as hematology, we have to become knowledgeable about the broad spectrum of internal medicine because I can get called at any time by anybody. In consultative service, we need to be both generalists and specialists – ready to go at a moment’s notice and ready to work with other health-care team members.

Often, consulting means suggesting procedures that might be unfamiliar or “scary” to those physicians who call our team; cardiovascular or neurosurgeons are wary of anything that might increase bleeding risk, yet we frequently prescribe anticoagulants to prevent pulmonary embolism which typically carries more risk than hemmorrhage if left untreated.

Occasionally we do meet resistance, which, again, is where we have to practice professionalism. The key to communicating with resistant specialists is to do so forcefully, calmly, and backed up with data. I tell my fellows and residents that it is fine to be aggressive, as long as you are right; if you’re not right, you better be able to back that up. So, if a physician is hesitant to follow our recommendation, we work toward a compromise (for instance, giving a lower, yet adequate, dose of anticoagulation and following the patient very closely for any event).

What advice would you give to fellow mentors?

I have found that there are certain venues where the best informal teaching moments for fellows take place, and all of them simply involve talking and learning.

After rounds – while we’re waiting for test results to come back, I’ll go get a cup of coffee in the cafeteria, sit down with the team, and we talk about a recent difficult case; at the microscope examining blood smears on the patients we saw (the quiet and isolated atmosphere provides a close bond between teacher and student) where we talk about that blood smear, corroborate our diagnosis, and discuss how we reached it; and in the lab. The discussions that happen in the lab are particularly relevant for hematologists.

Coagulation tests are conducted by a very small number of master laboratory technicians. Sit down and talk with them – they have plenty to share. A small investment can pay dividends later down the line, too, in terms of working up a complex patient. These technicians may not be at the patient’s bedside, but they are undeniably part of the team that saves patients’ lives.

The fourth time, unfortunately, is an autopsy. So much can be learned about the patient and the cause of his or her death while working with the diener.

What is the best advice you pass on to trainees in interacting with patients?

Straight talk: That’s the best advice I can pass on to trainees. Talk and talk some more. The worst thing is when you walk into a patient’s room after another doctor has been consulting with the patient or the family and you hear them say, “What did he just say?” Here communication failed.

When you’re talking to patients, you’re empathizing with them and establishing an underlying relationship and keeping the lines of communication open. Students and fellows beginning their medical careers can be, in a sense, afraid of patients and bringing them into the conversation or delivering bad news. That is unfortunate. Patients may have had a bad experience at another institution with a health-care team who had no idea what was going on yet was not honest about that fact. You, then, need to be that person who tells them how it is. They may be wondering if the other team made a misdiagnosis – it is our duty to explain to them that diseases can sometimes take a while to reveal themselves, that the previous doctor was probably using the best evidence available, and that we thus were able to diagnose the patient more quickly because of that doctor’s prior efforts and our new point of view.

Of course, in medicine, you will often run into questions that are unresolvable – you’re damned if you do and damned if you don’t. In my opinion, when you have this dilemma, you must involve the family. They need to know that we’re doing our best, that we don’t have an absolute answer for the situation, but that we can make a plan. Using this method (one that I try to impress on my trainees), we involve the patient and family in pursuit of the diagnosis.

So, talk – and talk frankly. I want the patient and the family to hear exactly what I am telling my fellows. In a patient visit, I will talk with the family first and then turn my eyes to the group of students and fellows so the family understands that everything I am going to say about the patient is going to be shared with them. The message is, “I don’t talk about people behind their back. If you don’t understand something or have a question or disagreement, I want to hear about it now, not later.”

We can’t back away from these difficult conversations, including those involving spiritual matters. The ill patient, particularly if seriously ill, always has questions that he or she hadn’t asked until illness forced the issue. The human spirit is strong and wants one thing: to love and to be loved.

For instance, I had a patient who asked me point-blank what his chances of dying were. I told him he had a 50-50 chance of dying. He needed to know because he wanted to repair a broken relationship with his son; he had reached out before but had been rebuffed. I asked for the son’s phone number, called the son, explained that I was his father’s doctor, revealed his father’s prognosis, and shared his father’s wishes. I handed the phone to the patient and left the room while they talked. A few days later, the son flew in to be with his father and reconciliation occurred. Those are the moments I live for: those moments when I can turn an awful disease into a meaningful family connection.

As physicians, we have a unique bond with the patient and his or her family that few others will ever have. If we ignore our patients’ questions, we are missing out on an important part of medicine.

What are the biggest challenges to successfully mentoring?

At the fellowship stage, intelligence actually plays an extraordinarily small part in teaching because, at this point, our students have already been vetted at three stages: they got into medical school, they got into their internship program, and they have started their hematology/oncology training program. So, the question of whether these fellows are smart or ambitious is not much of an issue.

While knowledge is not the biggest barrier to teaching trainees, the breadth of knowledge is very broad. I often say that about 95 percent of what an oncologist sees is going to be 10 or 20 common diseases (breast, lung, pancreas, colon, kidney, brain cancers, etc.). In hematology, however, we have hundreds of different diagnoses, yet you might only see only 10 of those in your entire career, but you have to be ready for them at any time. Some people might not enjoy the diagnostic chase, but I love it and thrive on it.

Intellectually, we know that a first-year resident is knowledgeable; problems that arise are largely behavioral, so it falls on the faculty to mold that behavior into the behavior of a good physician. Behavioral problems range from a lack of sensitivity, a poor bedside manner, and I have even had trainees who admit to not liking people.

The range of activities as a mentor is quite broad. Challenges can be elusive and one needs to be constantly receptive to even the smallest of hints that come our way in order to be the most effective physicians.