Dimitri Cassimatis, MD is a small-group advisor and course co-director for the cardiovascular pathophysiology course in Emory University's MD program. He is also Chief of Medicine at Emory Midtown Hospital. In this episode Dimitri talks about his journey from being a physics student to biochemistry student (working as a patient transporter) to pre-med student to internal medicine resident to cardiology fellow to ultimately his current roles as an attending. Dimitri also talks about his experiences being open to opportunities and enjoying the process of becoming the various roles he's taken on. His words of wisdom which include "I tell that to students that they should not stress themselves out about picking the one right thing that there are usually lots of right things. You just have to pick one of those right things and make the best of it and go with it."; "your job that you start out with right after training is just a starting point, and that from that you tailor that to where you enjoy spending time first by volunteering in those areas and then looking for paid opportunities in those areas to really shore up the amount of time you can spend there and that you can really tailor your career in many different directions depending on where your passions are." and "remember that education is a skill. You build it by practicing it and by paying attention to the feedback and trying to do things better, so look for opportunities to practice it. I would also remind everybody who's going to become a clinician that education is part of what you do every day with your patients. If you're going to be patient-facing, you're going to be educating your patients, and having skills to educate them is extremely important in being a good clinician for them. So even if you don't consider yourself an educator, if you're a clinician, you are an educator."

Hello listeners, welcome to Educational Landscapes, lessons from leaders. On today's episode, we are going to learn from Dimitri Cassimatis. Welcome to the show, Dimitri.

Thank you, Ulemu. Thank you very much for having me.

We are delighted to have you. So to begin, what is your educational leadership title or titles?

I am a small-group advisor at the medical school and I am the course co-director for the cardiovascular pathophysiology course for the first-year med students. Then I have a role that has a lot of... It's administrative, educational, clinical; it's being the chief of medicine at Emory Midtown Hospital.

Oh my. That sounds like quite a big role there, chief of medicine. So I would love to hear in these three roles that you have, what do you do?

Well, one of the things I love about the job that I have is every day is different. So there's no getting tired of the same thing every day. Some days are mostly clinical care, and my clinical work, I do outpatient clinic a couple times a week. I read outpatient echocardiograms or ultrasounds of hearts at least once a week. Somewhere around eight weeks a year I'm on service, on the inpatient service, either taking care of critical care cardiology patients or the admitted to the hospital, not critically ill cardiology patients.

So that's the clinical side. On the administrative side, there's a fair amount of hospital-type administration, think like credentialing, schedules, professionalism issues, peer review cases, putting out fires. There's stuff like that which comes, some of those meetings are scheduled, and some things happen. They happen when they happen and you deal with the fire when it happens. Then there's also part of that is trying to plan and improve and make things better for the future.

Then I would say the third part, the educational part, that also somewhat depends on the day and the time in that, for example, when the cardiovascular course is going on, which is five weeks at the med school, I spend a huge portion of my time teaching and preparing to teach the next day and preparing others to help teach because as the course director you prepare the small group advisors, you prepare fourth year. We have fourth-year tutors that help the first years. So there's a lot that goes into that course. In my life, I push the admin and the patient care as much as I can to the side during those five weeks.

When it's not those five weeks, it's a little more set in that I am a small group advisor. With that comes Tuesday afternoon and Friday morning most weeks and some Wednesday or some Thursday afternoons for me. Then in addition to teaching med students, there's teaching residents, teaching fellows at the hospital. I teach electrocardiograms to students and residents Tuesday and Thursday mornings at 7:00 AM most weeks. Then there's teaching in the course of clinical care. That's really fun to be at a teaching hospital where when you're seeing a patient in the hospital, you're usually seeing the patient with a fellow and either a resident or a nurse practitioner. There's always a chance to learn. They teach me as much as I teach them, and that's wonderful.

I love that. I also must admit I am overwhelmed about all you juggle.

Oh yeah. Then I have three daughters at home, two of them are teenagers, one's in elementary school and trying to be a dad and a presence at home, that also takes... One needs to be purposeful about that too.

Indeed. Indeed, and there is a lot of education in raising kids, so I can just imagine.

For sure.

So I would love to hear more, given the breadth of things that you have to do in these roles, what would you say are the core skills that you use in order to be able to get your work done?

So depending on the day you ask me, I'd probably come up with different core skills. The things that are coming to mind today, some of the ones I'd like to highlight. One, you have to be willing to do the work. There's definitely work. You got to prepare ahead of time and think about what you need to do tomorrow and be ready for it. A second one is, I think that whether it's teaching or patient care, you have to care about the people you're interacting with. I don't want to be the only one that knows that I care. I want them to know that I care, too. So I have to communicate to the student, to the patient that I care about them. I do that through time. I do that clinically with time, I think and listening.

It's very similar with students, and I can do that pretty well in my small group, but it's much more challenging to communicate that you care about somebody when you're teaching a class of 140. It takes different sorts of communication. But I think consistency and giving a message that you are doing the work for them, that you care about them, and what you want them to get out of the course helps, and being available for those who do want to ask you questions helps. I think if you are able to convey that you care about the student or the patient, that's almost the primary thing.

Then a secondary and almost as important is showing your passion for whatever you're teaching, showing your passion for whatever area of clinical work you're doing in which you're seeing a patient. If people can see that you are passionate about the subject that you teach or the type of medicine that you practice, they can see that. That I think can engender trust from your patients, and from your students, it can help them to get excited about the subject as well. Then I think try to model humility and imperfection because we're all imperfect and we all have holes in our knowledge and we're all constantly learning.

I think that if you can show curiosity and that it's okay to be wrong and it's okay to learn that that is something that I want our students to see too, that they don't always have to be right. They don't have to know everything. But I do want them to be curious and to want to find out what is the best known answer so far. Many of that overlaps very directly with clinical care. It's the same, patients want the same thing. One of the reasons I love teaching first-year med students is I have very similar conversations with a first-year med student as I do with a smart patient in my office who wants to know about why they're having palpitations or chest pain or shortness of breath.

People want to understand what's going on and they want it explained in terms that aren't full of jargon, and med students in their first year are very similar. They're not doctors. They don't speak the jargon fully yet. So you use the same skills to try to make something that could seem very complex, seem less complex when you explain it well to a patient or a first-year medical student. I want the first-year medical students also to see that that is a very important skill that they can translate their learning into an ability to teach their future patients, their colleagues, their family, about what's going on for them.

I love that. As I listened, the importance like you talked about modeling, caring, passion, and how important all of that is both to your clinical work and your work as an educator. So it makes me wonder, what was your journey that led to these current roles? Did you always know you wanted to be a physician, for example?

Everybody's going to have a very different journey, and I think it's always interesting to ask people their journey and what brought them to a place. I'm going to give you a short version. For me, I think I've always been very interested in science and how things work. I originally thought that I was going to be into physics and/or chemistry, and that's what I went to college thinking first thing I would do physics and understand the way of the natural world.

Then when I had one of those realizations that you sometimes get in college where you realize you're not as smart as you think you are, I realized I was definitely not as smart as I thought I was in high school, and as I tried to learn math to explain physics, after we got out of this sort of Newtonian physics and into particle physics and quantum mechanics type stuff, I was like, "I just don't get this. This doesn't make sense in my brain." So I changed scope a little bit and I thought, "Well, maybe I'll go into chemistry, biochemistry." Then I realized I didn't love sitting in a lab all day that wasn't fulfilling.

So I had many friends being in biochemistry, I was in classes with people in biology. I had many friends on the way to becoming doctors. They were pre-med, and I thought, "Maybe I should consider this." My way of considering it was to get a job as a patient transporter in the hospital at the University of Chicago, and I would push patients around the hospital and chat with them. As I pushed them around, and I realized that's what was missing for me in the lab was the human interaction side. So I turned the love of chatting with those patients into becoming also pre-med like many of my friends were, and using that biochemistry degree to go to med school and then didn't know what I wanted to specialize in med school either.

I think, I tell students all the time that you have to be open to all of it, try to be passionate and excited, and then that gives everything a fair shot. If you can be open to it and show those who are teaching you some excitement, they'll reflect that back to you, and then you get the best. You're giving each thing the best chance if you can go into it with a little excitement and think, "Maybe I would want to be a urologist," even if you're pretty sure you don't. Just try to be open to it.

I stayed open to things until way too late. I was like a procrastinator in making up my mind. But I think from learning the physiology of cardiac, the way the whole cardiovascular system works, I loved it, among other things, too. But that was always on my list. So I think internal medicine felt like a natural progression for med school for me, and it left a lot of doors open. Then, although I considered many subspecialties of medicine or even going and doing a second residency, because I was in the military, and you could do a second residency.

I did pursue cardiology, but I could easily see myself being happy in other areas too. I tell that to students that they should not stress themselves out about picking the one right thing that there are usually lots of right things. You just have to pick one of those right things and make the best of it and go with it. So for me it was cardiology, did the cardiology, did my time in the military for five years, and loved teaching residents and then fellows once I was an attending, and I knew I wanted to keep doing that when I got out of the military.

So I looked for places that I could do that as part of my day-to-day work. I felt really lucky that Emory had a position based at both Midtown and Grady when I was looking to get out of the military. So my first job was just being a clinical cardiologist split between Midtown and Grady. I got to work with mostly fellows and residents occasionally, but mostly fellows, and I loved it. I loved all the teaching that was involved in the clinical work. I was very fortunate to be able to work with a physician named Joel Felner, who is a long-time faculty at Grady in cardiology and was running the cardiovascular pathophysiology course for the first years. As life goes, a lot of times it's just where you are, who you happen to be with. Joel said to me, "Why don't you give a lecture? You like teaching. Come give a lecture to the first years."

I did that in my second year at Emory. Then he was like, "That went pretty well. Why don't you give a couple?" So my third year I did that, and then I think after the fourth year, he was like, "Why don't you just come teach the course with me?" So it just happened like that. I loved being around first-year and second-year medical students. I love their passion and their idealism about medicine and about what it can be. I love that they keep me on my toes. Not a year goes by that I don't get asked multiple questions that make me think about it in a way that I hadn't before, and I have to learn to be able to answer their questions. There are things that they just flat out teach me, too. So I love that.

From the beginning of being a faculty here, when I heard about the small-group advisor role, I thought, "What an amazing thing to be able to learn medicine again with first and second-year med students, talk about how one deals with the stresses of clinical work as they go through third year. I would love that." I remember at faculty orientation, I went up to Bill Eley, Dean Eley, and I said to him, "I want to do that. How can I do that?" He said, "Well, come back and talk to me in five years." He's like, "Get some time just being a regular teaching faculty and then we'll see."

But I didn't forget that, and I think after four or five years I... Now, first, you volunteer for things that you like. You volunteer to teach. You volunteer to be on committees, or you may volunteer to do research if you love research. But at first, you don't get paid for those things. You just volunteer. Then usually that can lead to some opportunities that can protect some of your time and you start to build on that and do more of it in your career.

So I think one of the take-home messages for people who are students or residents right now is that your job that you start out with right after training is just a starting point, and that from that you tailor that to where you enjoy spending time first by volunteering in those areas and then looking for paid opportunities in those areas to really shore up the amount of time you can spend there and that you can really tailor your career in many different directions depending on where your passions are. So I wound up with all these roles and it was one of the best days I had at Emory was when Dr. Schwartz called me up and offered me the position of being a small-group advisor.

Wonderful. That is amazing. I love, as you said earlier, being open and exploring and that helps you find these different opportunities and then you're able to focus in and work out, "Okay, which ones do I really want to spend my time?"

That's exactly right.

Yeah. Yeah. So now I'm wondering what do you wish you knew before stepping into these types of roles?

So I think that's a really good question and I do want to do a little caveat there that there is no good way to know what it means to be a physician before you start medical school. Even if you shadow physicians, or a parent is a physician, or you were a nurse, or you were an EMT, you cannot know what it is, unfortunately. You're going to have a sense, and hopefully it's a good enough sense that when you get there, you're not going to be like, "Oh my God, what did I just do with the last seven years of my life to become this thing that I don't want to be?"

So I think there is that caveat that some of it is on faith that you think, "This is going to be okay." Also it's like I think you don't realize before you get into medicine how different it is not one thing that becoming a pediatric oncologist is vastly different from becoming a primary care pediatrician, which is vastly different than being a radiologist for an adult. All of these specialties and settings in which you practice are so different from each other in that even within one thing, if you look at one adult ophthalmologist versus another adult ophthalmologist, the way they spend their time and their split between patient care, research, and admin and education; very different. All very, very different. So there is no one-size-fits-all and you can really tailor things to what interests you.

So back to your question of what do I wish I knew before I had gotten into it. I guess I am going to change it a little bit just to say that to the listeners. I would like to remind you don't go through the process of becoming whatever it is that you're becoming just to become that thing. Try to enjoy the process. If you're in med school, try to find what is enjoyable about med school. If you are in clinical rotations, try to make the best of that and enjoy that. If you are in residency, the same thing. If you can't enjoy some aspects of the thing that you're going through, then I think you're missing out.

Medicine, there is no Shangri-La at the end of the training. I think you have to enjoy the process of getting there. If you find that you really can't enjoy the process of getting there, that is a red flag warning sign that you may not enjoy what's at the end either.

So important.

Yeah, it's not to say that there will be bad days. There are always bad days. So just because you have a bad day in your second year of medical school or even a bad week, that doesn't mean you shouldn't be a doctor, but hopefully there are things you enjoy to balance those out.

Indeed, indeed. Now expanding on that idea of balancing, I am curious, given the different things that you do, what continuing professional development do you do to keep up with the needs of your various roles?

Yeah, that's a good question. So I'm constantly trying to think about how to teach better and how to be a better doctor. So you look for opportunities. Sometimes it's a course that you can take, but opportunity is built into everything you do because these days you usually get feedback. So if I teach cardiovascular pathophys, like we just finished a couple weeks ago, I'm going to get hundreds of comments on things that I could do better. I try to look at those for themes, not so much the one-offs, but what are the themes, and then really work on those for the next year. So there's always building an iterative improvement based on feedback.

I have a course co-director, Dr. Lakshmi Tummala, and she gives me feedback. I give her feedback. We're trying to help each other be better. There's other colleagues involved at the medical school who are looking at our course and also looking at the curriculum in general, and we're constantly thinking, you're talking to me here at The Hatchery at Emory where I spent the morning trying to think about how we can better prepare our students for Step 1, the USMLE Step 1, not just with how can we better prepare knowledge-wise, but how can we help them feel more confident and ready for the test with the knowledge that they have because so much anxiety about it. This was a room full of 12 senior educators trying to think about how to do this better.

I would say just keep your eye out for opportunities of things that look interesting to reflect on your clinical work and your educational work, research work, if you do research and how to do that better. Some of it is in groups and in discussions and other aspects of it you do on your own through self-reflection. I think it's very important to take time out on a regular basis to reflect about your life and your work and how you can be purposeful about doing things better.

Thank you. Thank you. Thank you. I feel like the next question, you've already given a lot of wonderful advice as we've listened to your respond to the questions, but is there any additional advice you would give to someone interested in doing the same type of educational or leadership roles that you have?

Yeah, remember that education is a skill. You build it by practicing it and by paying attention to the feedback and trying to do things better, so look for opportunities to practice it. I would also remind everybody who's going to become a clinician that education is part of what you do every day with your patients. If you're going to be patient-facing, you're going to be educating your patients, and having skills to educate them is extremely important in being a good clinician for them. So even if you don't consider yourself an educator, if you're a clinician, you are an educator.

Those skills of explaining something, asking for questions, explaining again, and thinking about how you can do that better and better, draw things out, and practicing that skill that you want to get better at, and that you in a career will almost always start by having to volunteer yourself in the areas you're interested in and then look for opportunities that grow from that. You never know what opportunities are going to come. You go to a conference to give a talk and somebody's in the audience and they reach out to you and that leads to you being on a committee, which leads to you being on another committee.

You just never know how things are going to go. I'm very happy here at Emory, so I haven't been looking for jobs elsewhere, but a lot of people, they do move to other institutions and your job can grow also as you move, because in order to lure you away, as you get more senior, other places will cater more to your passion and your interest in the job that they create for you or that they let you create for yourself at the institution. So it's like it's old advice, but whatever you try to do, if you try to do that thing well, it will lead to other opportunities, and you never know what those opportunities may be.

Okay. I love that additional advice. Perfect. So I think about as you're talking and opportunities, and I would love to hear more about the opportunities you provide to others. So how do you support or expand education in your profession or through your roles?

So I try to promote others to be passionate and interested in education. I start in that first year of medical school, part of my course is to have the first years teach each other and to practice their own teaching skills in their small groups, where they three times during the course have to take an appropriately scoped topic that they can teach it in 5 to 10 minutes, and they do that three times. It's this bite-size sort of teaching of each other.

We also have fourth-year med students teaching the first years in a cardiology elective, and those are fourth years who really like to teach. That's part of the reason they take that elective and they become sort of understudy small group advisors during that course. They really help teach their small group of M1 students, and that gives them practice in education. It gives them practice in cardiology. Although many of them don't go into cardiology, but they love the educational aspect of it and the interaction in their first years. Almost every year, the feedback I get is that the favorite thing about our course is their fourth-year student in many cases.

So in offering these opportunities, I think we are helping build the teaching skill and awaken the teaching passion in a lot of students. So I try to just provide opportunities for it and then encourage it along the way for residents and fellows that I work with as well and share the opportunity, but also like we talked about before, the passion in the topic and in the teaching. So I think that's the general answer of how I try to do that and create opportunities and draw others into it along the way.

Thank you. Thank you, thank you. As you think about the different things you've done so far, what has been one of your greatest successes?

So for me, one of my greatest successes thematically, is I think that in the last few years I've realized that it matters much more that I convey that I care about students and I'm passionate about cardiology than that I am some amazing world-class Olympic teacher in terms of teaching skills because I think that there are many different ways of learning, and in a class of 140 people, you're never going to cater to everybody's ways. But it is fairly universal that if you can convey passion and that you care about somebody, that that will help them in whatever way they like to learn.

I've gotten feedback in the last few years that has gotten through that students can tell that I care about them. They can tell that I'm passionate about teaching and cardiology. So for me, that has been a great, great success that I've been able to convey that. I hope that I can keep conveying that. What's challenging some is that the language and the things that one needs to do to convey that I think evolve over time, and that what students needed when I was a student in the '90s in medical school is different than what students respond to now a little bit.

Which now lead to my next question because as you're highlighting to be an educator, it means to be a lifelong learner, right? Along the way, how to respond to your students and all of that good stuff. So I am curious, what would you say your biggest growth opportunities are right now?

I think very specifically, a big, huge growth opportunity for me in the next couple of years, in specific to the way that I teach the first year of medical students is to move as much away from lectures as we can, and that's going to be a big challenge. We've been dependent on lectures for many decades, and to revamp a course and move away from that is going to be a lot of work and a lot of planning. I think some students will like it. Some students won't like it, and we want to do it well.

So that's sort of a next couple years big challenge. Move away from lectures. Move more to the smaller groups and the adult active learning kind of model where they're not just sitting there listening to somebody but have done some reading and are coming into class to discuss things. So that's one big challenge. Another big challenge is to focus on the positives and to hear the ways that we can improve as educators and as clinicians and be able to hear those need for improvement but not get knocked down by them or feel burned out by the dissatisfaction that can be there. So I guess to keep going is the short version of that, to just keep moving forwards.

I have some favorite quotes that I think of almost every day, but something from Winston Churchill is that, "Whether it's from success or from failure, what matters the most is to keep going." I remind myself of that. So I think there will always be successes and failures in our efforts with our patients and in our efforts with teaching. I hope to have the strength to keep going and not get burned out or just too fed up with the difficulties that are always there.

As I think about that, as you're talking about what keeps you going, I would love to hear what would you say you love most about your work and what you do right now?

I love most is seeing the light bulbs go off, seeing passion get awoken in some of the students both about cardiology and cardiovascular medicine, but also just about learning in general and about teaching and about being excited about being in medicine and have it feel exciting and interesting and see them look at it that way and not see them look at it as a burden or weight that is bringing them down. So those interactions where I can see that happening, the interactions where I can just listen to my individual students in small group and hear their stories and their ideas about medicine and about life and about the patients they're interacting with, those keep it worthwhile for me.

On the clinical side, when I can connect with a patient and/or the patient's family and feel like I have helped them to suffer less, whether it be through actually making their illness better or maybe helping them understand their illness better or just cope with their illness better. All of those can be very gratifying and help me. Maybe I still come home emotionally exhausted at the end of the day, but it is a sort of gratifying or fulfilling exhaustion.

Indeed. Indeed. Got to do the stuff, as you said, to prevent burnout. So wonderful that it's even after a long day like that, I totally resonate with that because sometimes when you've had those interactions, even though it's been a long day, you're like, "Oh, but it was worth it."

Exactly.

Yeah. So we're getting towards the end of the interview. Two more questions. The first, we've heard a lot about your experiences and what you've done, and so I want you to think overall and reflecting on your experiences to date, what would you say your passions are around education right now or do you have an educational philosophy?

I think I've conveyed a lot of my passions in some of the answers I've given already. I'd say probably with the educational philosophy. But I think for me, what is really resounding or what I feel right now with a lot of conviction is that you can put a lot of effort into the way you teach and trying to revamp curricula and come up with new ways of teaching something. That will almost never matter as much as if you can convey that you're passionate about it and that you care about the learner.

Now, there's always some, you have to be able to explain something. I mean, there is some basic aspects of things, but I think we can get too hung up in the how do we teach and not realize that the place to put so much energy and effort is the why do we teach, the passion about it, the caring about the thing that we're teaching and the person that we're teaching, that that matters more than the method, and that there are a lot of methods that can work. So I think that's a philosophy that matters a lot to me right now.

Teaching is a skill and you need to practice it and keep trying to do it better, but whether you're teaching at a whiteboard or you're using a PowerPoint or you've designed something where the students read ahead of time and then come in and discuss a case, the how is not as important as the overall, the oomph behind it comes from whether the students can feel that there's passion and care there, I think.

Thank you, thank you, thank you. So my last question, I recognize you are more than what you do. So what are some things you do outside of work to help you maintain joy in life and practice?

The important question for anybody to know what to do to restore your batteries. So my favorite things to do are to take walks. Atlanta is a lovely place to take a lot of walks in different neighborhoods, parks, the city. So I try every day to get out and walk for 20 to 30 minutes. So for me, that's a big thing. Just get outside and walk some.

A second one, and this is Greek heritage. I love food and I love eating. So having an enjoyable meal every day, which doesn't mean it has to be fancy or not. I mean, it can be at home. It can be not fancy, but having an enjoyable meal is important to me and restores my batteries. Then also, I love stories, and so whether that story comes in the form of reading from a book and it could be fiction or non-fiction or watching some TV, I restore myself through stories also.

Although I love reading, sometimes at the end of a long day, it's easier to watch a story, to read a story. So I do find myself, at the end of the day, especially long days, I'll watch 20 to 30 minutes of television, especially if there's something good I found that has a story. I mean, you learn, whether it's a book or a television show or a movie. There's a lot of really good stories out there about human nature and what it means to be human in different situations. So those are three things, walks, food, and stories that revive me.

Thank you, and what I love about this session we've had is we have heard your story and how your story really resonates with this idea of how we think of people as humans and interaction and relationships and all of that. So, thank you. That is a beautiful way to sum up our time together. But before I let you go, any last words of wisdom for aspiring educators or education leaders?

Thank you for asking me these questions and for your interest in me and in my story. You've done me great honor by asking the questions and listening, and you are a great listener. So, thank you. Let me on that theme, just say that as much as you can practice gratitude in life along the way, and think at the end of each day, what can you be thankful for, which I don't always remember to think about at the end of every day. The more gratitude you can carry with you and practice, the better.

Thank you so much. We are thankful for you, Dimitri.

Thank you. It was a pleasure to be here chatting with you today.