Tales from a Resident

Podcast Transcript

Steph Bayer: Welcome to another episode of Studies in Empathy, a Cleveland Clinic Podcast exploring empathy and patient experience. I'm your host, Steph Bayer, Senior Director of the Office of Patient Experience here at the Cleveland Clinic in Cleveland, Ohio. And I'm very pleased to have with me today, Dr. Cassandra Garraud. Dr. Garraud, thanks for joining us today.

Cassandra Garraud: Thank you. Thank you so much for having me. This is amazing.

Steph Bayer: Now I'm told that I can call you Cassie, right?

Cassandra Garraud: Yes, please.

Steph Bayer: Perfect. You are a third-year internal medicine resident at the Cleveland Clinic.

Cassandra Garraud: Yes.

Steph Bayer: Graduated in 2020 from the Touro College of Osteopathic Medicine, where you served as a vice president of the International Medicine Club. As a medical student, you visited Haiti along with other students and physicians, and together provided care to nearly 1000 patients.

Cassandra Garraud: Yeah.

Steph Bayer: I know you're passionate about helping others, and you chose to pursue medicine because it gives you the opportunity to impact lives in a positive and powerful way. It's amazing. Thank you.

Cassandra Garraud: Aw, thank you.

Steph Bayer: I'm super excited too, because you were recognized in 2021 as the Cleveland Clinic Hero Huddle for the personal impact you had on one of your patients. We're going to talk about that in a bit too.

Cassandra Garraud: For sure.

Steph Bayer: So we're so excited to get going. Let's do this.

Cassandra Garraud: Let's do it.

Steph Bayer: All right. First off, congratulations.

Cassandra Garraud: Thank you.

Steph Bayer: Graduation, it's officially happened, right?

Cassandra Garraud: It's happened. It's crazy to say. We have a graduate residency. When you've prayed so much to get to a certain point, then you're there and you're like, what?

Steph Bayer: What? Yeah, exactly. What's now?

Cassandra Garraud: What in the world?

Steph Bayer: So what's next for you?

Cassandra Garraud: Okay, so for this next year, I'll be working here. So, I'm not moving anywhere. We're staying in Cleveland.

Steph Bayer: Yay.

Cassandra Garraud: I'll be working in the cardiology department as a cardiology hospitalist. So essentially, I'll be admitting patients to the floor and cross covering the different cardiology services. And then this summer I'm applying for fellowship for cardiology too. So, this is a huge transition. I'm excited, but also a little nervous. But we got this.

Steph Bayer: We got this. What an incredible milestone though. Congratulations.

Cassandra Garraud: Thank you. Thank you.

Steph Bayer: So let's talk a little bit about you and your background. What inspired you to become a doctor?

Cassandra Garraud: I would say, so we'll have to take it all the way back. So, my parents, they had immigrated from Haiti when they're in their young adults age. They didn't know each other. They met each other here.

Steph Bayer: I love that.

Cassandra Garraud: But growing up, we always heard stories about how hard it was to get medical care there and having to go for miles. Maybe that hospitals didn't have the resources. So, I kind of already had that inkling in the back of my mind. And then in high school, this is kind of weird to say, but my mom made me shadow her OB-GYN. Don't worry. She wasn't a patient while I was shadowing.

Steph Bayer: Thanks for clarifying.

Cassandra Garraud: We got to clarify that. But it was just so nice to get that first light of the patient-doctor relationship. And then in high school, when I was 16, I went to this event, it was called the National Youth Leadership Forum on Medicine, and it was at Georgetown. So, it was a bunch of teenagers going to Georgetown doing these different activities. And also, a random thing to say, I saw my first C-section there, and then that catapulted me.

Steph Bayer: When you're in high school?

Cassandra Garraud: In high school. I was the only one not cringing in the room.

Steph Bayer: That's incredible.

Cassandra Garraud: And it's so not to go on a tangent, but it wasn't until I was a med student doing my third-year clinical rotations actually on OB-GYN when it hit me, why did they let us see that? There's just like no small feat. This can be a gruesome, but also lovely procedure. But I don't know, did anyone pass out in that room? Goodness gracious. But all of those different experiences just really led me to try to at least aim to become pre-med and then medicine, and then it was a wrap from there.

Steph Bayer: Where did you grow up?

Cassandra Garraud: So I grew up in New York. Anything above the Bronx is upstate.

Steph Bayer: Oh, is that the line, above the Bronx.

Cassandra Garraud: Yes, that's the line. That's the line However, actual upstate New York will never claim you, like Rochester and Buffalo. So, I'm not sure if you know where Westchester and Rockland County is, it's just up there. You got to pass, well, it used to be called the Tappan Zee Bridge. It's no longer called that, but it's about 30 to 60 minutes from the city depending on traffic.

Steph Bayer: So upstate, you grew up upstate.

Cassandra Garraud: Yes, of course.

Steph Bayer: So I mentioned in the intro, but you were recognized as a Cleveland Clinic Hero in our Hero Huddle process for the personal impact that you made on one of our patients. And for those listening that may not be familiar, I'm going to take a second, explain our Hero Huddles. This is where we look for individuals in our organization that go above and beyond their role, and they show up for patients in ways beyond what the job would ordinarily call for. And we want to thank them and recognize that commitment because that's really what makes us who we are.

And with that, we give this recognition and we let our executive team know, and the leadership of the hospital also has a chance to say thank you. So, upon getting this here Hero Huddle, we don't often have medical interns. So, you were an intern when you got this.

Cassandra Garraud: Yes.

Steph Bayer: It's really unusual to have that. But what happened, and from what I understand, and this is where I'm hoping you'll fill me in, was that there was an urgent finding on a patient, and you convinced the patient to turn the car around and come back to the hospital for medical attention.

Cassandra Garraud: Yes.

Steph Bayer: Can you tell me more about?

Cassandra Garraud: Oh my goodness. Okay. So let me just paint the picture for you. So, you're coming in as an intern, and just for those who may not be familiar with the medical process, an intern is someone who, they graduated from medical school and this is their first year of residency, and your kind of like the ground runner for the team. There's a senior resident above you and an attending physician above you.

So, when this happened, it was my last rotation of intern year. So, this is the rotation where it's, I'm not going to say make or break, but you have to show forth that you know, next week on July 1st, I'm ready to be a senior.

So, we were doing our rounds, and the night team was presenting a patient to us. And as they're presenting, we got a page about the patient. The patient was quite disgruntled already, he wanted to leave. He already came for a second opinion from another facility where he had left AMA.

Steph Bayer: AMA is against medical advice, right?

Cassandra Garraud: Exactly. Yep. Correct, correct. As someone who you know has never seen the patient before, and you already know that there's a conflict and emotions may be running high, it could be a little bit of already some first contact experience.

So, we weren't really sure how it was going to go. He was a gentleman that was middle aged. He had some past medical history of coronary artery disease. He had a stent in the past. He was a smoker. He had a history of cancer in the past. And he was just coming in for something that at first glance seemed very nonchalant, as my toe has been discolored for some months. I don't really know why it's discolored. I'm just trying to figure out why this is. He wasn't feeling that much pain. He does a lot of work outside, very manual, was able to do his work. This was just something peculiar. But it just catapulted into something that was very, very serious.

Now, when we first met him, the big thing was, at least for me, when I see a patient that's angry, I don't want to just know what's making them angry. I want to know why. So, it's not you are coming in five minutes late that they're angry. There's something underlying.

Steph Bayer: It takes a lot of maturity to do that at such a young part of your career. That's very impressive.

Cassandra Garraud: Yeah. The biggest thing is really just to sit and listen and just try to have the patient feel heard. Because they didn't come in angry, it's something that continued to escalate.

So, throughout his stay on our service, he was on the internal medicine service, myself, my senior, and my attending, we really spent a lot of time trying to figure out, why do you have so much mistrust in the system? Because that's where a lot of his anger was coming from; feeling offensive, making sure he has to advocate for himself, really going through with a fine comb through all the details of the plan, the management.

And it ended up being such a lovely experience. He and his wife just opened up. Once they realized that, listen, we're actually on the same side, he ended up opening up to me about just a horrible experience that he had in the past where he really had to take the reins upon himself to get himself the proper medical attention.

So, for me, the biggest thing was building rapport with him, building trust with him. And we did this every single day. So, when it came time for that fateful day, essentially, we were waiting on something called an echocardiogram. That's an ultrasound of the heart. And we really want to see what the results of his are, just based on the different disease processes that we've seen during his admission.

But it was Father's Day weekend and throughout this whole week, he's been telling me how close he is with his children. Family is huge for him. This is what motivates him to get up in the morning and everything. And he just wants to go home to his boys.

So, oh my goodness. We set up everything where he would literally leave on Friday, come back on Monday, he'll finish the rest of his procedures. I called his primary care doctor. Everything's set up. We just needed this ultrasound of the heart.

I'm calling the echo all day. "Can we get a tag? Please, please, please." So, we got the ultrasound. He has all his things packed. He has his pants on, everything ready to go.

Steph Bayer: He's leaving.

Cassandra Garraud: He's just leaving, patient gown nowhere to be seen. I can't convince him to stay for the results. And I'm like, "All right, if anything pops from the results, I will call you. But for now, here's your list of appointments. You're coming back on Monday. Enjoy Father's Day and what have you."

We do ultrasounds. We're waiting for the results to come back. Patient left. Mind you, it's not even long, within 10 minutes. I'm looking at the ultrasound as it's coming back on our computer system. I'm like, you know I'm not a cardiologist, but this doesn't look normal. And then in the same line, my pager goes off. Of course, it's the cardiologist that's reading the echoes that day.

He's like, "So this patient has wall motion abnormalities." Meaning there's certain parts of the heart muscle that are not moving or contracting properly. And that's an issue. And by the way, there's a blood clot in the heart.

So of course, so many things are going through my mind, but the biggest thing is I need this patient to come back right now.

Steph Bayer: I need to keep the patient safe.

Cassandra Garraud: He needs to come back right now. Oh, my goodness. So, I think at that time, that's when I really had to put my thinking cap on and stand on both of my feet and just make quick decisions. Because of course, yes, I'm going to talk to my attending, yes, I'm going to talk to my senior, but I need to make this call right now while he's still possibly in the vicinity of the hospital.

Steph Bayer: Right. Yeah.

Cassandra Garraud: So we were able to call. I mean, Hammer called him, of course. Hammer called his wife, calling his primary care doctor, called everyone. We finally got into contact with him, and literally he says, "If it wasn't for you specifically, I would not have come back."

Steph Bayer: Oh, wow.

Cassandra Garraud: So it was actually that trust that I've built with him, and the team built with him throughout his stay here that brought him back and was able to get that further medical care and workup that he needed.

Steph Bayer: There's a saying, and I believe in it, that trust is gained in drops and lost in buckets.

Cassandra Garraud: Yes, yes, yes.

Steph Bayer: And you said that you had to build that trust day by day by proving and standing by what you said, and we can lose that so quickly.

Cassandra Garraud: Oh my goodness, yes.

Steph Bayer: So it's amazing that you were able to build that rapport and convince the patient and save his life.

Cassandra Garraud: Yeah, for sure.

Steph Bayer: I understand that you actually waited hours past the end of your shift to make sure that he returned.

Cassandra Garraud: Completely.

Steph Bayer: Thank you for doing that.

Cassandra Garraud: Oh, that's no problem.

Steph Bayer: When you were given the Hero Huddle and you were asked about that dedication and deserving patients, I'm told that you said, "What if this patient was my mother, my father, my child, or even myself?"

Putting yourself in someone else's shoes, well, that's the epitome of empathy. Does that empathetic approach come easily for you, naturally for you? How do you develop that?

Cassandra Garraud: So I would say it's kind of twofold. Yes, there's an element that does come naturally to me. I think at least what I tend to do, I've had my own set of challenges, at least coming into the medical field. What I typically do is I lean back on my difficult experiences, and I remember how I felt during those experiences and things that I've overcome. And I use that to lead me through what the patient could be feeling.

So, as I had said, when I was explaining about dealing with a patient that may be a difficult patient or may be an angry patient, and wanting to know what is driving that, that specific thing is what helps you connect with that patient. And it kind of just brings in the humanism of the patient and it just becomes so much more than a person or a room number or somebody you just see on the computer and you're writing in orders for them. They're human beings.

Steph Bayer: There's some studies that say when we, there's a radiology study actually as we're talking radiology, that once they attach the picture of the patient to the results, they were more accurate. That once you see people as people and not just bed space, we give better quality care and safer care.

Cassandra Garraud: Agreed.

Steph Bayer: It takes a lot of maturity though, to be able to lean into empathy the way you do, and then to be able to put yourself out there. So, I commend you for being able to do that so soon in your career.

Cassandra Garraud: Aw, thank you.

Steph Bayer: As you think about medical training, do you think there's a focus on the value of empathy through your education? Or are there things that we could do in a medical program, a medical school or residency program that could enhance that?

Cassandra Garraud: I would say anyone who's either gone to medical school, PA, nursing, no one can deny that they haven't heard the word empathy or compassion or something of that sort. I would say it's more so how specifically is it taught? Is it in lecture form? So, I think one of my first experiences is as a medical student, we were in cadaver lab, and essentially these are folks who dedicated their bodies to the study of medicine. She was actually my advisor, and she was also the professor for anatomy.

But what she did was she took off all of the handkerchiefs off every cadaver's face. Because often, let's say you're a medical student, you're so stressed about anatomy, you just want to learn X, Y, and Z. What's this nerve? What's this blood vessel? And you forget that that's a person. This is not like a mannequin or a dummy. It's a actual person who's had a life, had family, had their own hopes and dreams.

So, what she did for us is she made us look at all of their faces and read the notes. A lot of them did write a note when they declared that they want their body to go to medicine. And oh my God, I'm not going to lie. I remember hearing one of the notes and I was crying in the corner, and I didn't want to look like I wasn't tough enough the first time in cadaver lab. But it's those instances that, as I said, going back to the human portion, that brings that out.

Now, when it comes to trying to make a curriculum or something, as I said, that is very difficult in my experience. So, we have a set of board exams as medical students. There used to be a specific part exam. If they were like an MD student, it was something called clinical skills. If you're a DO student, this is called physical exam or PE. This is an exam that shows how you interact with patients. We no longer have it due to Covid, but there's a humanistic sector of the exam that you actually get scored upon. But as I said, it's really just going to be really your experiences, and maybe I would say, whether it's med school or residency, having time carved out to actually reflect about your patient experiences and how you felt during them, maybe thinking, oh, how that patient felt, because exercising that will actually lead you a little bit more to discernment when you encounter someone in the future.

Steph Bayer: That is very insightful. And I love the idea that first you've got to make space to recognize it and to feel it, and then you can then take action on it.

Cassandra Garraud: Exactly.

Steph Bayer: One of the actions that we tend to teach from a skill-building perspective with empathy is communication. Because so much of how people receive empathy is what we say. What ways were you able to develop communications skills? You clearly have exceptional skills. How were you able to develop skills in your training though? Were there behaviors that you saw in mentors or others that were teachable moments for you?

Cassandra Garraud: Yes. I would say being able to observe someone's bedside manner works wonders. I'm the type of person where I really want to feel connected to my patient. I want that patient to trust me. I want the patient to, most importantly, feel safe. So, when I interact with my attendings, or even in med school, the times that I'm shadowing, or even when I was pre-med or working as a scribe, working with the attendings, I would always watch super closely, one, how they speak to the patient. Do they let the patient talk to them? Are they interrupting the patient? Or do they have one foot out the door? Are they sitting in the room?

I'll never forget, there's just simple things like holding the patient's hand or sitting down. If this is a longitudinal patient, you see them multiple times, remembering something that's maybe non-medical about the patient and just seeing how the patient lights up and how much they open up. Those are all things that I kind of put in my toolbox.

So, when it came time to now, I am a doctor and I have my patients in my clinic as internal medicine resident, we do have a primary care clinic, and we see these patients every five weeks. So, you build a wonderful rapport with them. And the big thing, I just really want my patients to feel safe with me. So, in terms of communication skills, that could be just letting them speak. It could be speaking in a tone that's not super loud, even though I am a loud person. Reading body language is a huge one. Even if they're just making eye contact with you, if they're looking at the ground, if their chin is down, all these little things help to paint a picture, and it just gives you a better perspective.

And then at a point when and if the patient does feel comfortable, they'll open up to you. And for me, when that happens and they cross that threshold, it's such an honor for me. It's something where you're just like, wow, I might be the only person that knows this information about the patient. And that's just so special to me.

Steph Bayer: Wow. That's amazing. And I want to reflect back some of the behaviors that we teach in our empathy skills that you mentioned without maybe even realizing it. But you said, when providers have one foot out the door, it's so true that patients pick up on how far we are into the room. When we sit down. And sitting down, you don't have to spend any more time, but patients perceive that you did if you sit down and go eye level with them rather than hover over them.

And I love that if I can pick up something about a patient that's not related to who they are in this patient setting, that's such a way to build relationships. And studies actually show that the reverse of what we think happens, we think if we care too much, we're going to burn out. It's actually the opposite.

Cassandra Garraud: I know.

Steph Bayer: When you care and you build connections, that's actually, studies show, keeping us going and giving us that resilience. So, you're on your way, man.

Cassandra Garraud: That's literally what gets me through a hard service. Not to go on a tangent, but it was this year, I was on service with one of my mentors and advisor, Dr. Donato. Hey.

Steph Bayer: She's so good.

Cassandra Garraud: And our service just had a lot of very, very sick patients, complicated past medical histories, complicated home situations. And we got to the hospital very early, leaving super late. You go home, you eat, you go to sleep. And it was just very, very easy to feel burned out. And one thing that I do, and people might look at me crazy, but instead of going home, I go to one of my patients' rooms. And I still, if there were three patients, I would always just go in and check in on them again. And I would just sit down next to them, and we would chat for five, 10 minutes. And you just, all the stress and worry from the day just kind of settles and dissipates. And the patients were really excited that you came back to their room again after rounds.

Steph Bayer: Absolutely.

Cassandra Garraud: So I'm like, yes, I'm helping you, but you don't know how much you're helping me too.

Steph Bayer: On that note.

Cassandra Garraud: It's so sweet.

Steph Bayer: It's so great. We talk a lot about doctors being empathetic to patients, but did you see, being a resident is not easy, the workload, the hours on a day-to-day basis, the grind that you have to do.

Cassandra Garraud: Tell me about it.

Steph Bayer: Did you find situations in which patients were empathetic towards you?

Cassandra Garraud: Oh my goodness, yes. I'm going to give you two scenarios.

Steph Bayer: Oh, good.

Cassandra Garraud: So the first one, I would say, my intern year, we used to work 20-hour shifts. We don't work 20-hour shifts anymore. But when patients realize that you've been working long hours, they get concerned. So, you would see, round on them in the daytime, you round on them in the afternoon, you're still there at midnight. The nurse is paging you; they want to talk to somebody. And they're like, "You are wearing the same clothes? So, you didn't go home? Did you eat today? What's going on with you?"

So, I think it's so nice when patients actually also take a step back and they see their physicians or PAs or nurse practitioners as human beings as well, because it just helps the relationship gel a little bit more.

I would say the next instance is in my primary care clinic, because of those patients, I have a really good relationship with them because I see them continuously.

So, when it was time for me to graduate and to hand off my patients, and why, my patients, all my patients were devastated. They're like, "So what are you going to do now? Where are you going to be? Can I follow you there? What's going on?"

Steph Bayer: What a compliment.

Cassandra Garraud: Oh, I loved it. I loved it. And when you opened up today's episode, you asked me about graduation, how it's feeling. And it's like, yes, I did have my graduation ceremony, I did get the wonderful certificate I can put in my future office. But for me, graduation was really my last week in my primary care clinic when I actually realized how much of an impact I made on my patients. Some of my patients were crying. I hugged them. We were walking arm and arm to the door. And I just realized, wow, I actually made a difference. They do see me in this positive light. They do care about what I think of them.

Steph Bayer: Absolutely. Absolutely. So, I'm going to leave it to give you a chance to say, what question did I forget to ask you, or what advice would you give another resident? What did we leave off the table that we should have talked about?

Cassandra Garraud: I would say a lot about this episode, we spoke a lot about empathy between the provider and the patient, but I think it's super important to realize it's not limited to that. So, let's say you are a resident yourself, have empathy for your intern. You were just an intern; you know how it feels. Or have empathy for your medical students. I think a big one is having empathy for your attending. Oftentimes, we put our attendings on pedestals. They know everything. They know exactly what they're doing. They're at home sleeping as I'm working here. And a lot of times that's not even what's going on. And when you're attending opens up and shares with you how much they're doing, you're like, "Okay, you can go home. I got this. The patients are tucked in."

But lastly, I would say have empathy for yourself. We go through so many traumatic experiences, whether you are aware of it or not, whether it's breaking bad news or whether it's seeing a patient pass away, or just doing something happy, just getting through your long shift, you're on call, we're always moving forward to the next thing. Okay, let's get into residency. Let's get into fellowship. I need this job. Oh my God, am I doing research? Am I doing this? There's always something forward that we're looking towards, but we just need time to look within and realize, this may have been a bad day, but I have a hundred percent success rate of surviving all of my bad days. I'm still here. So have empathy for yourself, I would say.

Steph Bayer: Well, I can't improve upon that. You're already a phenomenal doctor with this focus and empathy and the way that you care. Thank you for staying with us for a little longer.

Cassandra Garraud: Oh, of course.

Steph Bayer: For what you're going to give to this medical profession of ours here. So, thank you.

Cassandra Garraud: No problem. It was my pleasure.

Steph Bayer: This concludes the Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcast. Subscribe to the Studies in Empathy podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcast. Thank you for listening. Join us again soon.