This am has been an interesting juxtaposition of following twitter during the state of the science, and being reminded of the power of a graciously led small group meeting.

I would not qualify myself as a skeptic, but more as a user without training in the multiple areas for which a Clinical informatics system can be adapted to improve our care, And having recently been faced with the common problem of being told the system at my new institution will take months to change, I was hopeful for new quick tools.

Joy Goebel, Kelly Chong, Sangeeta Ahluwalia and Karl Lorenz gave an  organized presentation of the issues involved in the why, how what and so what of Clinical info tools.

We were reminded these tools and systems are very early in development and that the technology will progress even as we work to develop tools.

We were reminded of the need to work with stakeholders and end users to develop clinical information tools, and if the application of Implementation Science (a term I had not heard before).

Greater La VA system has a consult tool, but not other notes yet, and is just beginning to generate reports. They seem to have a great and very multidisciplinary development group, and I they may create national VA templates and reports that others can review.  It had nice features like embedded tools like the PPS and embedded references which would be great for multiple users to help standardize documents.

There were many good questions asked about limitations, and I realize that the issue still returns to understanding my system and what its benefits and limits are. Any other Cerner users with templates for notes or ideas about how to highlight goals of care info in the large volume of documents generated?

I learned much from blogging, as it caused me to think and listen more critically. Thanks to the academy for the opportunity.

Diane Dietzen, MD Baystate Medical Center

Ok -so it only took me 40 min to post the first one so this posting will get better.

This session was about motivational interviewing and was led by Julie Childers and Bob Arnold. We were very interactive and engaged and it was very heartwarming to see a large roomful of colleagues who have really good communication skills but want to think critically about how to get better. One of the things this meeting regularly provides is that warming of the heart.

Specifics:

Techniques- we reviewed standard interviewing to prescribe change, and the spirit of motivational interviewing: curiosity, respect for autonomy, patient as expert, physician as consultant, collaboration and empathy. The OARS of motivation interviewing were described: O- open ended questions, A-Affirmations R –reflections and summaries.

The difference between following up with a question, or following up with a reflection was stressed .The reflection can add a little more of your assumption about what was said, and can advance the conversation, so it is a good technique to understand.

And then we practiced, and by reflecting had a really insightful discussion of creative outlets and how they relate to palliative care practice in a small group in a very short time.

I do agree with the comment made in the session that reflecting creates more vulnerability for you as an interviewer, but also for the patient. In practice the art is as always to balance reflection with questions or summaries, or silence.

In the discussion, issues of “agenda “and right and wrong” in meetings with patients and families and concerns were described. I think all of us have thought about and about the idea that in palliative care there is no right answer for a given patient or family , there are their answers which we may not agree with. If we find continued disagreement our job should be to find out why the patient/family is choosing the option they are and provide support.

Again valuable to add another frame to think about how we communicate, and how to teach this to others.

Newly inspired by Christian Sinclair’s presentation I am happy I challenged myself to be a blogger at this meeting.

I certainly agree that the title “An unlikely union- Palliative Care and Wellness “seems apt, and quite intriguing. And at a session I attended yesterday the emphasis was on integrating palliative care, and so I was eager to learn how the framework of wellness care might fit.

Cobie Whitten, Becca Hawkins and Gregg VandeKieft did a great job of providing a framework for the discussion reviewing a little about chronic illness care, cancer survivorship, and models for care. The discussion was very lively

Themes:

The language- there was much talk about the connotations of palliative care and wellness, and the hope that associating the two would further the overall discussion about quality of life. This despite the still difficult connotations of palliative care for some providers.

The need to address the cancer survivor population comprehensively and provide ongoing support- extending way beyond treatment. This likely involves better education of primary care providers about medical issues in follow-up but also other supports. Palliative Care providers can participate in developing this education.Creating a specific post treatment plan for education also seemed a good way to help convey this information to other providers caring for the cancer survivor.

We need to create these models for other populations like dialysis patients with models similar to many cancer centers and for the chronically ill in general. Other sessions here have addressed models for this type of ongoing wellness care.

The importance of rehab and nutrition in wellness, a point I have recently come to recognize in my palliative care practice.

What can I do to use this information? Colleagues at my new place of employment have shared with me their thought about an outpatient wellness center that includes palliative Care, but at present that is only one of those grand ideas. That is a grand 10 year plan. Perhaps sooner I can investigate with my cancer center colleagues and nephrologists wellness follow- up for their patients, and how primary care is involved.

So is this grand ides thought provoking for others – or have you had so many thought provoking new ideas in the last 24 hours that this still seems” unlikely”?

I will try to remain focused on more discussion of this, even with the 50 ideas I will  add to my to do list next week.

Diane Dietzen, MD Palliative Medicine Physician, Baystate health, Springfield, MA

Our palliative care interdisciplinary team (IDT) meets every morning, and reviews nearly all the patients on the inpatient service, new patients seen in the outpatient clinic, outpatients in need of active management of some aspect of their care (typically pain medication), and patients under our care who have died. It’s a unique and comprehensive meeting that gives us the opportunity to hear about each of our patients from the beginning of our interactions with them, making  transitions between providers and location of care much easier than what I am accustomed to. I haven’t seen other IDTs in action so I was curious to see how other programs do it. As it turns out, the Mt Sinai team presented a model not just for an IDT meeting, but specifically how they do their weekly case conference.

They have developed a highly structured model for presenting a pre-selected case to their interdisciplinary team, called “Bring it to the table” (BITTT), referring to the goal of presenting cases that bring a need for help with a tricky management issue, interpersonal dynamic, or with learning potential. Under their old system, they found that the medical side tended to dominate the discussion, and part of the motivation for revamping their conference was to encourage greater participation by the non-medical members of the team. To that end, the facilitator for their conference is typically their chaplain. There are time limits placed on each section of the conference, with time for the clinical case presentation, clarifying questions from the group, and group discussion. This has improved attendance and participation in their conference, and particularly participation by the non-medical members of the team as there is time dedicated for them to ask questions. The time limits imposed also allow for two case presentations weekly, one by each consult team.

As part of the structure of their conference, the facilitator asks the presenting team: “You bring this case to the table because…” with the team filling in their reasoning. I loved this question, because it does force the presenter to be thoughtful and focused on what they are hoping to accomplish with their presentation. This was a very common theme when I was a chief resident and helping residents to prepare for their M&M presentations, when they often chose cases that were extremely complex past the scope of what could be presented in an hour, and needed to identify what specifically they were trying to communicate to the audience. This skill of identifying your teaching (or learning) objective is not intuitive to all learners and educators and I think is really critical for those of us entering the world of clinical education. I love the explicit emphasis placed on it by the Mt Sinai team. My team does some case presentations in our weekly palliative care conference, and while I think the strict structure of the BITTT model does have some drawbacks, it’s worth considering for us as our section grows and the potential for conference chaos increases.

Does your program have a regularly scheduled case conference? How does it work?

Meredith MacMartin, MD, HPM Fellow at Dartmouth-Hitchcock Medical Center