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Are You a Leader or a Jerk?

My Chief Medical Officer, Dr. Chris Hughes, and I have been discussing leadership and communication, as we promote the development of effective behavior in ourselves and in our staff. During a recent chat about one tome on the subject, “What Got You Here Won’t Get You There” by Dr. Marshall Goldsmith, Dr. Hughes succinctly summarized the book in four words: “Don’t be a jerk”.

This light-hearted comment holds great wisdom, and insight into the common pitfalls of leadership.
We all start out with similar traits on the leadership trajectory. Young leaders are typically really smart, personable, ambitious and happy to go above and beyond to do whatever it takes for the organization. Their amiability activates others. They get promoted.

With the power of position and the increasing pressures of leadership, many of these superstars go off the rails because of their way of relating to others; particularly in handling conflict, listening respectfully, problem-solving and maintaining their composure. In other words, they act like jerks. Stress can cause an otherwise perfectly lovely person to act like a jerk, and it is incompatible with effective leadership. Of course, the higher we rise in the workplace hierarchy, the less likely we are to receive honest feedback about how we treat others!
We are now in a highly scrutinized and regulated industry that requires our best efforts to both honor our mission and thrive in this environment

Under these highly intense and game-changing conditions, the jerk can emerge:

  • Use of power or status to win arguments and drive change
  • Insensitive or aloof persona
  • Poor frustration tolerance
  • Low insight into the impact of their style and behavior on others
  • Reliance on obsolete strengths; failure to adapt to changing conditions
  • Trail of hurt feelings among those in their wake

It is essential that leaders at all levels recognize the need for and develop leadership skills that will help us navigate the white water of healthcare reform and hospice’s transition into a mainstay of the healthcare continuum. The ability to engage and motivate employees during difficult conditions is a core competency. Vision and experience remain necessary, but are no longer sufficient.

Barbara Ivanko, CHPCA
President & CEO
Family Hospice and Palliative Care
Pittsburgh, PA

Find out how to develop and strengthen the key relationship between physician and executive leaders at this new one-day program on August 17 in Chicago. Learn the best strategies and most innovative tools to take your hospice leadership team to the next level at the Intensive for CEOs and CMOs: Building an Exceptional Physician/Executive Leadership Team. Learn more at www.aahpm.org/SummerInstitute.

Kate Lally, MD FACP – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Kate Lally, MD FACP, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
Many people have, and continue to, influence my work. When I teach about having end-of-life conversations I often quote Dr. Nancy Angoff, a mentor of mine in medical school who specialized in treating patients with HIV. When I was in medical school, people were frequently dying from AIDS and Dr. Angoff helped young people navigate an illness that was ending their lives much too soon. In addition to Dr. Angoff, I also often cite a hospice nurse I used to work with, who taught me the language to speak with my patients about the harms vs benefits of various treatments. I was struggling to explain the studies showing the risks associated with tube feeds in a dementia patient to a daughter who was distraught over the imminent death of her father. She was very upset and accused me of starving him. The conversation was failing when the nurse approached and said “Dr. Lally stopped the tube feeds because I asked her to. He was drowning in them, they were going into his lungs and he couldn’t breathe. He is much more comfortable now.” Her approach was so clear and kind, that it made me re-think how I had these conversations. Just recently I worked with a psychiatrist who explained the terminal nature of Alzheimer’s to a family that was struggling with understanding the rapid decline of their mother in an incredibly compassionate and clear way. These people and more have influenced my work and help me get better every day.

Where do you see yourself in 5 years?
I love the field of palliative care. What I love most about it is the broad array of opportunities available to those of us who practice it. I am first and foremost a clinician, and when I go through difficult times at work it is always an encounter with a patient that reminds me how much I love what I do. I recently was able to work with a patient with dementia and agitation in an assisted living, our team had the opportunity to work with geriatric psychiatrist, geriatricians, the PCP, the patient and family and nurses at the assisted living to think though a good plan for this patient to manage his agitation, avoid a hospitalization and reassure his family. What is so exciting about palliative care is that we get to be at the forefront of changing models of care. We get to sit at the table with CEOs and administrators and help design programs to improve the care of our sickest patients in a system that we all know doesn’t serve our most vulnerable well. In the next 5 years I hope to continue to expand and improve my clinical work and continue to have the opportunity to innovate and change the system to provide better care to those who need it most. I hope to become known as an innovator in the field, someone who works across disciplines and specialties to improve end of life care for all out patients.

What is the best advice you have ever received?
I feel like at different points of my life I go around repeating different bits of advice that I have received. Most currently I have been considering something I heard on a documentary about particle-accelerators…

The secret to success is to be able to go from failure to failure with undiminished enthusiasm.

I have this idea that if you fail enough and learn from each of your failures you will get stronger and better with each attempt. From working with our patients to figure out a reasonable plan of care that may deviate from the norm, to working with insurance companies and health systems to think about how to revamp healthcare in a larger sense, our field is all about innovation. We need to make mistakes, learn from them, and try again. Maintaining a positive outlook can be tough at times, but I try to remind myself that it is all part of the process, and that we need to fail in order to succeed.

Arif Kamal, MD – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Arif Kamal, MD, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
My work in Hospice and Palliative Medicine is most influenced by the memory of my mother. It was my experiences taking care of her that inspired me to shift my career towards this discipline, and it is her lasting memory and influence that keeps me passionate about improving the lives of others with serious illness and their loved ones. Secondly, Amy Abernethy, my longtime mentor and friend has shown me how to translate that passion and inspiration into meaningful research, effective leadership, and compassionate clinical care.

Where do you see yourself in 5 years?
In five years, I see myself furthering the quality of palliative care delivery across the discipline through research and leadership activities.

What is the best advice you have ever received?
My favorite advice is about the role of a leader – “The role of a leader is to define reality, and in the end say thank you. Otherwise, the leader is a servant” – Max Planck.

ICD-10 Program Focusing on Hospice and Palliative Care

Dear Education Colleagues,

Are you familiar with all the ICD-10 changes coming your way? Are you certain exactly where to find morphology codes? What has the 8-week rule regarding initial and subsequent MIs changed to? How does laterality effect your coding? How will you correctly code for symptom treatment? What about the management of terminal illnesses with related conditions? Discussions will include the significant advancements between ICD-9 and 10, the newly created complex guidelines encompassing codes, rules including Laterality, Encounters, Activity, and Place of Occurrence. The newly created ICD-10 structure accommodates both technological and medical advances and, allows for more flexibility with the highest level of specificity and clinical detail. New features include the relocation of the Neoplasm Table and why the Hypertension Table is no longer necessary.

We will answer your questions, address your concerns, and teach you the myriad of changes with respect to new laws and requirements in Hospice and Palliative Care at the ICD-10 Boot Camp for Hospice and Palliative Care.

October 1st is fast approaching, let us lead you to Your Success for ICD-10!

Jean Acevedo, LHRM CPC CHC CENTC
Acevedo Consulting Incorporated

Amy Frieman, MD – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Amy Frieman, MD, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
Dr. David Muller, Dean of Medical Education for the Icahn School of Medicine at Mount Sinai, has most influenced my work, not only in hospice and palliative medicine, but as a physician. Dr. Muller was the Director of the Mount Sinai Visiting Doctors Program when I was a resident at Mount Sinai and later when I was an attending. I have had the amazing opportunity to call him both a mentor and a friend. Making house calls with Dr. Muller, I immediately understood that he was the type of physician that I would strive (and continue to strive) to become. He clearly recognized the person behind the list of medical diagnoses. He listened more than he spoke, and his presence in itself was a comfort to his patients and their families. As a resident, on one of my first home visits with Dr. Muller, I remember visiting a patient with dementia and spending the vast majority of the visit seated in the living room, speaking with the patient’s wife. Initially, I wondered where the patient was and when we would examine him. As Dr. Muller continued to provide support to the patient’s wife, I realized that this would be the most important part of the visit that day. This was the first time that I truly recognized that doctoring comes in many different forms. Dr. Muller also encouraged me to become involved with medical education and helped me to foster my interest in medical humanities.

Where do you see yourself in 5 years?
In five years, I see myself continuing to expand palliative care services at Meridian Health. While palliative care has become an important part of the culture of our inpatient and post-acute care facilities, I want to continue to work to build upon our outpatient palliative care services. I plan for our home-based palliative care program to continue to expand. In addition, I envision our office-based palliative care practice extending to multiple locations. As Meridian continues to actively address health care reform, my goal is for palliative care to be firmly entrenched within our system’s population health management initiatives, our accountable care organization (ACO) and our clinically integrated network. As a patient advocate, my vision is that in five years, the delivery of palliative care at Meridian will be seamless, and that all patients who would benefit from palliative care will have access to these services no matter where they are in the care continuum. In addition to continuing my work at Meridian, I plan to become more active on the statewide level in New Jersey, advocating for increased use of palliative care and hospice services for our vulnerable patient population.

What is the best advice you have ever received?
The best advice that I have ever received is to “choose to be happy.” Growing up, this was a message that I frequently heard from my parents. I believe it is even more pertinent to me as an adult, particularly now as a hospice and palliative medicine physician. Being surrounded by patients with serious and often terminal illness, I have tried to embrace this advice. I make a conscious effort to recognize all of the gifts that I have in my life every day, and to be grateful for each and every one of them. I look at my amazing family and friends, my good health that allows me to leave the hospital and go for a run, my rewarding career, and I know that I have been blessed in life. Rather than focusing on the negative and allowing myself to become discouraged by difficult issues, I try to choose to be happy. Though I am certainly not always successful in this mission, more often than not, I find that happiness is a mindset and a way of looking at life.

Robert Crook, MD FACP – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Robert Crook, MD FACP, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
I especially want to recognize my wife, Annette, for her seemingly infinite love, support and sacrifices during this journey.
I am grateful to have worked with many skilled physicians, nurses, social workers, and chaplains who have taught me much and shared their passion for palliative care. I thank the Dominican Sisters of Hawthorne who introduced me to the field and for the privilege to work alongside them as an aide at Holy Family Cancer Home while in college. I appreciate Paul Mihacevich, Sister Luke, and all the nurses sharing with me their skilled care for dying patients and their families. I am grateful to the Hospice of Northwest Ohio for teaching inquisitive medical students and allowing me to learn from a master in compassion, Dr. Marsha Paul. It was an honor to learn under Dr. Michael Harrington during residency at Case/MetroHealth and I am appreciative for all the extra time he spent mentoring me. I give special thanks to the Hospice of the Western Reserve and Dr. Chuck Wellman for always being a resource over the years. My former partners Dr. Ann Moore and Dr. David Tribble have forever positively influenced practice. I appreciate the time, active mentoring, and friendship of Dr. Dan Masion, who taught me many things including some of the soft skills which were seemingly quite hard. Lastly, I am thankful for my current partners and the incredibly skilled and supportive team at Mount Carmel, especially Lori Yosick, Dr. Phil Santa-Emma and Dr. Walt Ferris.

Where do you see yourself in 5 years?
I hope to serve where called and where my gifts best match the world’s need.

What is the best advice you have ever received?
“Watch your thoughts, they become words. Watch your words, they become actions. Watch your actions, they become habits. Watch your habits, they become your character. Watch your character, for it becomes your destiny.” -Frank Outlaw

Highlights of the May Issue of the Journal of Pain and Symptom Management

Highlights of the May Issue of the Journal of Pain and Symptom Management
Listed below are a few articles from the most recent issue of the journal:

Promoting Evidence in Practice

Octreotide for Malignant Bowel Obstruction: Commentary on Currow et al.
Sebastiano Mercadante

Original Articles

Double-Blind, Placebo-Controlled, Randomized Trial of Octreotide in Malignant Bowel Obstruction
David C. Currow, Stephen Quinn, Meera Agar, Belinda Fazekas, Janet Hardy, Nikki McCaffrey, Smon Eckermann, Amy P. Abernethy, and Katherine Clark

Measuring End-of-Life Care and Outcomes in Residential Care/Assisted Living and Nursing Homes
Sheryl Zimmerman, Lauren Cohen, Jenny van der Steen, David Reed, Mirjam C. van Soest-Poortvliet, Laura C. Hanson, and Philip D. Sloane

Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives
Melissa M. Garrido, Tracy A. Balboni, Paul K. Maciejewski, Yuhua Bao, and Holly G. Prigerson

Review Article

Measuring Experience with End-of-Life Care: A Systematic Literature Review
Jessica Penn Lendon, Sangeeta C. Ahluwalia, Anne M. Walling, Karl A. Lorenz, Oluwatobi A. Oluwatola, Rebecca Anhang Price, Denise Quigley, and Joan M. Teno

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit aahpm.org.

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Laura Gelfman, MD, MPH – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Laura Gelfman, MD, MPH, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
My experience caring for Ms. R, an older woman with metastatic breast cancer and severe post-herpetic neuralgia, continues to shape my approach to palliative medicine. I cared for Ms. R throughout my clinical fellowship, through multiple hospitalizations and ultimately, I cared for her at home until she died.

These experiences taught me the importance of finding ways to ensure Ms. R’s voice was heard throughout her illness, which slowly diminished Ms. R’s closely guarded and highly valued independence. When her oncologist offered her more chemotherapy, Ms. R could not say “yes” because she suffered from her previous chemo and she could not say “no” because she was afraid of what the future might look like. Her sons and her doctors all agreed that her decision to not decide was a decision that we would support, all the while working to control her symptoms.

Our symptom management focused on the ebbs and flows of her somatic and neuropathic pain, opioid-induced constipation and acute delirium, each critical to her care. This required effective communication and care coordination among her care team, including her oncologist, homeopathic doctors, family and home care team. I witnessed firsthand the devastating effects and unmatchable joys of caregiving. Through my continued relationship with her family, I have come to appreciate the waves of bereavement and the meaning of sharing memories. When I look back at my fellowship, I realize that Ms. R taught me the fundamental tenets of palliative medicine, and the intense satisfaction and privilege of providing our care to patients with serious illness and their families.

Where do you see yourself in 5 years?
In 5 years, I plan to transition from a mentored K23 funded investigator to an R01 funded independent investigator whose research improves the care of older adults with advanced heart failure. Under future NIH career development funding, along with my Hartford Centers of Excellence Collaborative Pilot Award, I will design and pilot test an intervention to improve the communication skills among heart failure clinicians. With future R01 support, I will conduct a randomized controlled trial to test the intervention. Improving communication skills of heart failure clinicians has the potential to better outcomes of patients living with heart failure by aligning treatments with their goals of care. I will continue to leverage national funds to build a coalition of both funders and key stakeholders within HPM as well as outside of HPM to be able to move the field forward. I will use these awards to ensure that I improve the quality of care for patients living with serious illness and their families, and advance the field of HPM.

What is the best advice you have ever received?
Throughout my childhood, when I faced a challenging decision or problem, my parents encouraged me to take a step back with the simple phase that my father learned in the Navy “KISS: Keep it simple stupid.” To this day, I remind myself of this advice as I sit down to write a grant or a manuscript, to break bad news to a patient or a family member, teach medical students the fundamentals of pain management, or encourage a fellow to practice a new communication skill. By breaking down a complex problem into smaller pieces, I have come to realize that these challenges become more surmountable, not only for me as a clinician, educator or researcher, but for patients, families, learners, trainees and mentees.

Hunter Groninger, MD FAAHPM – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Hunter Groninger, MD FAAHPM, was selected based on his involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired him over the course of his career. We are sharing some of his answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
One of my favorite aspects of our field is the diversity of the professional base: people don’t come to HPM because they love a particular organ system; they come because of their own personal and professional stories. Because of this, so many rich experiences inform folks moving into the field. I can think of a dozen individuals who have significantly impacted my work and it would be difficult to choose the one who has influenced me the most.
But here is one of those rich experiences that stands out: as a fourth year medical student, I did a rotation in palliative care with Dr. Daniel Fischberg. One day, we were rounding on a patient, an elderly woman dying in an intensive care unit. Her large family was gathered around the bed, trying to accept the inevitable decline of this matriarch. Understandably, they were so incredibly sad. It was palpable in the room. I remember feeling paralyzed, like there was nothing more to be done that might help them through this time. Then, in the middle of talking with some of her children, Dan gently moved the conversation to life before this hospitalization. What did she like to do for fun? What gave her joy or excitement? Within a few seconds, the room filled with laughter and storytelling. The gathering suddenly seemed like a celebration. I was stunned to witness this simple magic, and I knew I wanted to be able to help patients and families just like this.

Where do you see yourself in 5 years?
I see myself exactly where I am now: serving the community of the Washington, DC, metro area. When I arrived here in 2006, the city of Washington, DC, had one of the lowest hospice utilization rates in the nation and one of the highest rates of in-hospital death. Patients and families were just beginning to learn of the supportive benefits that palliative care can provide. Since then, many HPM clinicians have worked hard to change this for the better, but there is much more to do. I aim to see palliative care deeply implemented into the inpatient and outpatient fabrics of my hospital; our current project to integrate palliative care upstream with advanced heart therapies is one part of that. I also want to create strong partnerships with community-based HPM providers to make this care truly seamless. And we need to study what we implement so we can always improve and extend these benefits.

What is the best advice you have ever received?
Founder of the Zen Hospice Project Frank Ostaseski has developed five precepts that he uses to teach caregivers of the dying. They are all important to me, but one in particular I find myself practicing many times a day: find a place of rest in the middle of things. Working with seriously patients and their families could not be more rewarding. It can also be very challenging work. Then put this hard work in the context of the rest of life – family, friends, financial responsibilities, hobbies, spiritual life – and it can be tricky not to feel pulled in too many directions. I remember talking with Frank about this specific precept. His suggestions were simple: pause and breathe before entering a patient’s room; enjoy a red light instead of being frustrated by the commute; when you wash your hands dozens of times on hospital rounds, just focus on washing them, and let your mind relax rather than race from thought to thought. When I follow this advice, I feel focused, energized, and present to these special moments with our patients. I can bring more to my work, but I also take away more from these rich experiences and look forward to the next encounter.

Jessica Merlin, MD MBA – Inspiring Hospice and Palliative Medicine Leaders Under 40

This post is from one of the Inspiring Hospice and Palliative Medicine Leaders Under 40. Jessica Merlin, MD MBA, was selected based on her involvement in AAHPM, educating others about hospice and palliative medicine, participation in charitable work, and mentoring of students or residents. The honoree was then asked who inspired her over the course of her career. We are sharing some of her answers in this post. Check back regularly for posts from other leaders.

Who has most influenced your work in hospice and palliative medicine and what impact has he or she had?
I am fortunate to have had one of the giants in our field, Dr. Christine Ritchie, as my steadfast mentor. Christine has guided me through every aspect of my work, from study design to helping me with the often challenging transition from fellow to faculty. Whenever I find myself in a difficult situation, I always try to channel Christine’s compassionate but always practical and level-headed advice.

What is the best advice you have ever received
The best piece of advice I’ve ever received was actually from a TED talk, but is something that Christine and I have also often discussed, and something that I have personally experienced many times: “Chance favors the connected mind.” In other words, if you are engaged in your surroundings, passionate about what you do, work well with those around you, and open to new possibilities, amazing opportunities will come your way.

Where do you see yourself in 5 years?
One of my biggest opportunities has been to work in a very understudied area within palliative care – chronic pain, particularly in individuals with HIV. Approaches to chronic pain are often different than approaches to pain in serious illness disease, and include a focus on improving long-term pain and function through treating mood disorders and addiction when present, and optimizing person-centered self-management strategies. Over the next five years, I hope that my work will allow me to bring these approaches to community-based palliative care, and put chronic pain more on the “palliative care map” as a key area of importance within our field.