Make Your Own Rules: Dr. Michelle Kittleson

Interviewer: Francis Alenghat, MD, PhD, University of Chicago

Cardiology MagazineMichelle Kittleson, MD, PhD, FACC
Professor of Medicine at Cedars-Sinai, Director of Education in Heart Failure and Transplantation, and Director of Heart Failure Research at the Smidt Heart Institute.

Describe what you do on a day-to-day basis in your current roles.

As a heart failure transplant cardiologist at Cedar Sinai, I spend a majority of my time taking care of patients, because I love taking care of patients.  I do heart failure, transplant, and general cardiology. I like that dynamic. The majority of time is with clinical work—inpatient, outpatient, and procedures like biopsies. I also read echocardiograms, and for my non-clinical time, I'm director of the Heart Failure Fellowship, and I like to say I'm 100% clinical and 10% research, wherever that fits in.

Everyone's career takes different paths. Could you describe what led you to these roles? Why did you choose this sort of an academic cardiology pathway, and are there people who helped form those decisions along the way?

I think we all climb on the shoulders of our mentors. We're so lucky to have all that support. I found people I wanted to be like and modeled myself after them. The two greatest mentors in my life were Dr. Lynne Warner Stevenson, heart failure and transplant cardiologist, when I was a resident at the Brigham; and then Dr. Stuart Russell, heart failure and transplant cardiologist who was my mentor when I was a fellow at Hopkins. They really inspired me to pursue a career in which the primary focus is outstanding patient care, and that inspired everything else, whether it's education, research, or administrative leadership.

I ended up working with my next mentor, Dr Jon Kobashigawa, back in 2006. When I finished fellowship, my dream was to move out to California. It was my husband's dream as well. So, we had this personal and professional combination of perfect fit, living in Los Angeles, and being able to work in a premiere heart transplant program. And I came into my career as a cardiologist really just wanting to take care of patients and took a job that would allow me to focus primarily on patient care.  That's really what motivated me. I wanted to take care of really exciting, dramatic, complicated, heart failure and transplant patients. That's how I ended up where I am.

At some point, did you think your career was heading in a different direction like more research-based or more education-based?

I'm so delighted where my career's ended up. I left fellowship thinking I'm going to do mainly clinical work and maybe get involved in some research that interests me. Leaving fellowship, it seemed there were only three paths: you're a pure clinician, you're a clinician educator, or you're a physician scientist. Now, 15 years later, I see many amazing paths that I had never even conceived.  The ACC, for example, has so many opportunities to get involved with research and education on a national level. For example, the ACC ACCSAP question writing committee is where I first got involved almost 10 years ago, with a group of people passionate about clinical medicine and how to write great questions to get the most important educational details passed on to other ACC members. I really loved that. And that led to networks and connections built on other things I've done with ACC. I tell trainees or junior faculty now, it's very flexible. There are many opportunities to define your role. You love taking care of patients, but you want something else in your life, something else that makes your job a little more interesting and gives you connections, even outside your institution, to impact care on a different level.

One of the keys, hearing you describe it, is maintaining some degree of openness to new opportunities and understanding that you're not locked into one path.

100%. I have a rule: Say yes, unless you have to say no. Let me give you an example. I have 3 kids, they're 9, 6 and 4; they're perfect in every way. Especially when I'm here talking to you and not getting them ready for school in the morning. I had them between 2012 and 2017 and I think my brain basically shut off for the year of pregnancy and the year of taking care of an infant. I kept my patients alive. I kept my family alive. That's pretty much all I could do, and I said no to everything else, and thank goodness I had supportive colleagues and mentors who said, we get ittake care keeping your patients and your family alive. Everything else will wait. In 2018, my brain woke up when the youngest was a year old, so I found myself becoming more interested in things like, "wow, that is a research question I kind of just shoved to the back of my mind." All of these ideas popped up and I started saying yes to almost everything, because it's finally sounded exciting again. You'll know your priorities. Everyone's timeline is different. Don't compare yourself to others. Your priorities are the right ones. Your timeline will work out how it needs to work out.

How do you work on research projects with trainees?

I've modeled how [Dr. Lynne Warner Stevenson] structured my first research experience into what I do with residents and fellows. They may come to me saying, I'm kind of interested in research, and I'll try to give them a burning question. I keep a little email file of little burning questions I have, and then when someone approaches me, great.  Four or five residents right now are working on these projects. Are we going to change the world? No. But they will have a great experience with how research works. The devil's in the details. How do you craft a question? How do you answer the question? How do you present the data? And they'll also do something important that someone who cares for a patient will find useful.

What would you advise trainees to maybe do differently than what you have done in the past?

You know, the only thing I would really advise is to fix your priorities based on what matters to you as opposed to what you think is supposed to matter to you.  When you're a great shining star of a trainee and people say to you, you're going to be a leader in the field and you're going to change the face of medicine—and mentors will say that because they care about you, they're proud of you, and they're so impressed by your experiences. But you know what? It's okay if you save yourself. That's not what I want right now. I want a job that prioritizes my geographic location or my family situation. Or there can be other priorities in your life, and life is long. You have no idea what twists and turns your career may take. Your priorities are the right ones. Your path can find so many different outlets you never would've realized when you left fellowship.

If you're on the fence [about academic cardiology versus pure clinical] I think it makes sense to take a position that offers you both options where you're at a center that has trainees, so you're still involved with that educational growth and then you may branch out to more opportunities that aren't purely clinical.

Are there certain things you do that help you with work-life balance?

Work-life balance—it's such a funny term. I've never felt that I have to come in the front door and all of a sudden work just stops, because sometimes I'm still needed. And that's okay. I don't mind triaging a few nurse calls from outpatients when I'm on vacation, because it's just easier for me to take care of it. And I have the support my spouse and my kids. I kind of get that. I think the most important thing for me is not that I have work life hermetically sealed and separated, but that I derive joy, fulfillment, value and appreciation from both things that I do – my work life and my home life.

You have been very active on social media, on Twitter in particular, with a popular series of, essentially, clinical pearls for cardiologists, but also all physicians and especially those in training. How did you get involved in this?

You mentioned I'm active on social media, particularly Twitter. Actually, I'm only on Twitter. I don't really understand social media. I think I have a Facebook account. Instagram, I don't know, I feel like someone signed me up and I get these random spam mails from Instagram. So, it's Twitter. Where did it come from? I'm always ranting on rounds. There was a show—maybe, it's still on TV—called NCIS. There was this guy named Gibbs who was the Navy mentor who worked with his protegees to solve crimes together. Gibbs, this mentor guy—if his trainees made a mistake, he'd slap them on the back of the head and say, Gibbs Rule #1, blah, blah, blah, blah, blah. Now I never slapped a trainee on the back of the head ever, but I loved this idea of Kittleson Rule #1. I'd go around rounds, saying these things. One year, years ago, a fellow compiled about 30 of them at the end of his fellowship and emailed them to me. And they'd kind of make the rounds every so often. Trainees would have copies. Then in 2018, one of my fellows said, listen, you need to put these pearls on Twitter. That's very scary. I don't think people want selfies of me eating breakfast. No, no, no, that's Instagram. One day we were on rounds, and he was talking about some study that I haven't even looked at yet. How do you know about this study? It's on Twitter. And he showed me his phone and he helped me set up my account. Oh, this is kind of scary. There's so much going on. After a while, I'd say that my rule is if I've said it on rounds, I'll put it on Twitter. So, my trainee says to me, so-and-so sleeps on 2 pillows. But why did they sleep on 2 pillows? Are they comfortable? Or can they not breathe? Oh, gosh, I didn't ask that. Oh, if you didn't think of that, I bet other people didn't think of that too.

So, again, it's very organic. If I said it to you, I'll say it to the world, and that's where I started with Twitter. No one is more surprised that people are so open to it. I'm thrilled. I'd like to think of Twitter as like each Tweet is a mitzvah, a good deed you put out into the world, and you hope people derive some benefit from it.

I'm conscious that there's this potential in life for social media addiction, where the more clicks you get the more dopamine is in your brain, and I don't want any more dopamine in my brain, so I actually mute notifications as soon as my tweets come out. I schedule them in advance. I do go back and look at the comments because that's polite. And I'm appreciative of people who engage, but it saves me from that constant cycle of do-they-like-me or do-they-not-like-me and forces me to think of it as I'm putting something good out there, and I hope people like it. So that's my philosophy about Twitter.

I assume you plan to continue.

I don't think the stream of rules will run dry because I'm always interacting with trainees and there's always things to say.  Twitter definitely has a dark side. There is the bright side of the fantastic engagement. And then there's the dark side. The joke on Twitter is if you post that you like apples, everyone will castigate you for saying you don't like mangoes. You're not going to please everybody. And so I think you have to have a thick skin and go in there recognizing that people might not like what you say. But if you said it, you stand by it.  If someone doesn't like it, it doesn't mean it wasn't good. So have that confidence in yourself before you put things out there. Don't say anything, of course, that you wouldn't say to someone's face.

Have you found that doing this has led to new opportunities, not just in the ether, but also in the rest of life?

It's extraordinary. Actually, can I tell you a funny story? I'm on the phone with an insurance company. They didn't want to approve an ambulatory monitor for this patient who had palpitations, and I'm telling the person the story, and finally we come to consensus and decide the best path for the patient. He's happy. I'm happy. And before he hangs up the phone, he says, and by the way, I'm a huge fan of yours on Twitter. Whoa, this really is all-consuming, but that's just a tiny example. I've definitely been invited, I think, to give talks based on my presence on Twitter, invited to co-author articles, because, you know, heart failure/transplant is a small world, and a lot of them are on Twitter. I think they get to know you by the interaction. So, it's really been incredibly fruitful and rewarding in that sense of making these connections that turn into real-life connections as well.