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Building Bridges, Breaking Barriers…February 16 preconference

Although I was faculty rather than participant, this workshop about horizontal and vertical violence (“Bullying”) was a learning experience for me. As the only physician on the panel I expected to be isolated, to feel like a concentration-camp guard at the Holocaust Museum; instead I was surprised at the number of physicians in the room, often, it seemed, with experience on both sides of the bullying divide.

While the literature suggests that nurse-on-nurse bullying is slightly more common in health care, that has not been my experience. Trained in an environment in which bullying was a norm, physicians have a tough time escaping from that practice. It was clear that this group of physicians was determined to heal, and that the others on the palliative care team were equally determined to travel on the same journey. Most of us experience bullying in our work, and the nursing studies which dominate the literature suggest this is a significant factor in leaving the profession.

Modern teaching theory suggests that adult learners do well with short doses of didactic material and much better with “showing” rather than “telling.” In the interest of “showing” we inserted an episode of “horizontal violence” into the didactic session as an unannounced role play, with one presenter harrassing another to the extent that the room became visibly tense and uncomfortable, while the undermined presenter grew more flustered, shaky, dropping her materials. We stopped almost immediately to debrief. One of the participants asked “what could we have done to stop this,” and we spent much of the rest of the meeting examining this question in parallel experiences of “real life.”

Reflective practices which teach us to move toward appropriate action in spite of our ever-present fears are the foundation of resistance to bullying. Gifted teacher Don Marks hleped us understand the effect of these practices, actually decreasing the activity and size of the amigdyla, the brain’s “fear center,” increasing the size of the insula, the compassion center.

Again, understanding that “showing” works better than “telling,” we demonstrated two practices, reflective writing and a meditation. Participants were enthusiastic, understanding how these practices could well move them to a place where they could better intervene in bullying episodes on behalf of themselves or others.

Patrick Clary, MD

New Hampshire Palliative Care Services

Building Bridges, Breaking Barriers…February 16 preconference

Although I was faculty rather than participant, this workshop about horizontal and vertical violence (“Bullying”) was a learning experience for me. As the only physician on the panel I expected to be isolated, to feel like a concentration-camp guard at the Holocaust Museum; instead I was surprised at the number of physicians in the room, often, it seemed, with experience on both sides of the bullying divide.

While the literature suggests that nurse-on-nurse bullying is slightly more common in health care, that has not been my experience. Trained in an environment in which bullying was a norm, physicians have a tough time escaping from that practice. It was clear that this group of physicians was determined to heal, and the that the others on the palliative care team were equally determined to travel on the same journey. Most of us experience bullying in our work, and the nursing studies which dominate the literature suggest this is a significant factor in leaving the profession.

Modern teaching theory suggests that adult learners do well with short doses of didactic material and much better with “showing” rather than “telling.” In the interest of “showing” we inserted an episode of “horizontal violence” into the didactic session as an unannounced role play, with one presenter harrassing another to the extent that the room became visibly tense and uncomfortable, while the undermined presenter grew more flustered, shaky, dropping her materials. We stopped almost immediately to debrief. One of the participants asked “what could we have done to stop this,” and we spent much of the rest of the meeting examining this question in parallel experiences of “real life.”

Reflective practices which teach us to move toward appropriate action in spite of our ever-present fears are the foundation of resistance to bullying. Gifted teacher Don Marks helped us understand the effect of these practices, actually decreasing the activity and size of the amigdyla, the brain’s “fear center,” increasing the size of the insula, the compassion center.

Again, understanding that “showing” works better than “telling,” we demonstrated two practices, reflective writing and a meditation. Participants were enthusiastic, understanding how these practices could well move them to a place where they could better intervene in bullying episodes on behalf of themselves or others.

Feeling Our Fire

Earthy, dynamic, funny, rich in the wisdom of connection, reflection, and rejuvination…This describes this morning’s plenary by Dr. Sherry Showalter. Her words and movements celebrated this work we do. She reminded us that that which is to provide light, must endure burning, and that we who strive to heal, must, each day, heal ourselves.

Her message invigorated us with renewed purpose, inspiring us to go forward with fresh eyes and weightless spirit, to bear witness and share strength, to open the door with an open heart and open mind, to achieve comfort, to offer hope, to create healing.

Wado Dr. Sherry “Charles” Showalter. Wado!

Karen Whitley Bell, RN, CHPN

After the Bad News… When Patients Hear Something Different than What Was Said

How many times have you begun a conversation with a patient or family, only to discover their understanding of the situation is far different from what the referring physician has shared with you?

All too often, it seems, judging from the large attendance at this informative, lively session that led attendees through the labyrinth of difficult, high stakes conversations. The role-play exercise—a PC consult with a determined mother of teens who believes she’s discharging to rehab to “get stronger for chemo” — stimulated a discussion that identified techniques, pitfalls, and ethical boundaries.

The take-away of techniques included three communication approaches: offering a hypothetical situation (have you thought about what you’d want if the chemo isn’t effective?), offering hope/worry language (I’m hoping you’ll feel better and be able to go home to spend time with your family, but I’m worried that your body is very sick, and this might not be possible) and naming the dilemma.

Some techniques to avoid common pitfalls included communication with the team after to conversation to ensure a common message and reduce team distress, and avoiding splitting, even bringing the referring physician to the meeting, if possible.

The concept of planting a seed—taking the conversation only as far as the patient appears able—emerged as we explored the ethical boundaries of sharing unwanted news, weighed with our duties to the patient and family to provide accurate information to empower informed decision making.

While we recognize that some patients and families may stay “stuck,” the goal of these conversations, and indeed all care, is to maximize the chances for better outcomes. Thank you Drs Jacobson, Thomas & Jackson for an enlightening session.

Karen Whitley Bell, RN, CHPN

Every continent except Antarctica

Julie Bruno, Director of Education, AAHPM

I had the opportunity to represent AAHPM at the 18th International Congress of Palliative Care in Montreal in early October. This was my first time at this Congress and, with the help of AAHPM member and Congress attendee, Dr. Nancy Hutton, we talked with people practicing palliative care from every continent of the world except Antarctica at the opening reception. (Thank you, Nancy!) Many stopped by to learn about AAHPM and many were interested in our educational resources: The Primer of Palliative Care, Unipac QR, the Unipac Series, the newly released recording of the AAHPM Intensive Board Review Course and the upcoming Annual Assembly in Vancouver. It was interesting as a staff member to consider how AAHPM resources may serve a more international audience. I also appreciated greeting several AAHPM members who dropped by to say hello.

I would like to thank AAHPM President Dr. Sean Morrison for spending time staffing the AAHPM booth with me. Throughout the week, we talked with attendees about Board certification and on line resources – both the AAHPM website for professionals as well as the patient family website, palliativedoctors.org . The Congress was trilingual (Spanish, French and English). If we think we struggle with a clear definition of hospice and palliative care in the US, imagine the challenges at this international conference!

Two stories from my time at the conference are staying with me… Mr. Li Ka-shing has developed National Hospice Service Program in Mainland China through the Li Ka Shing Foundation (LKSF). They have 220 field staff, 31 hospice units and have served 94,212 patients as of August 2010. They target underprivileged patients and provide free home-based care with a key focus on pain relief. The LKSF foundation has donated a total of US$ 40M, 89% spent on medications. He concludes his story by saying that they are serving 1% of the people who are dying in China. (www.hospice.com.cn) That took my breath away!

The other story came from Susan Kristiniak from Abington Memorial in Philadelphia. She shared the story of attending the 2009 AAHPM and HPNA Annual Assembly in Austin along with some of her colleagues. They were so energized by the conference that they went home and developed a four-hour nursing in-service training with a goal of reducing unrelieved pain. Using hospital data, they were able to prioritize need and started with the post-surgical unit that included 77 nurses who were mandated to attend this training. The unit showed a significant reduction in pain scores. Based on the feedback from the nurses on that unit, the training has been refined and is being rolled out on the orthopedic unit. To learn more about this project, Susan welcomes emails at skristiniak@amh.org.

The International Congress happens every other year. It is worth the experience.

Local HPM Programs Help Physicians Meet Practice Pathway Requirements for HPM Board Certification

This post is reprinted from the Spring 2010 issue of AAHPM Bulletin.

by Larry Beresford

Some hospice and palliative care programs are helping physicians in their communities to qualify for board certification in hospice and palliative medicine (HPM), offering “practice pathway” opportunities to accumulate necessary hours of caring for patients while learning the medical subspecialty on the job.

When HPM was recognized by the American Board of Medical Specialties and ten of its constituent specialty boards, it was hailed as a great achievement for the field. However, it posed the challenge of how to qualify enough physicians to fill medical positions in hospice and palliative care organizations, especially after 2013, when completing a full-year fellowship becomes a prerequisite for HPM certification.

Although the practice pathway option is available until 2012 for mid-career physicians to sit for the HPM boards without first completing a full-year HPM fellowship, a more urgent deadline is looming for those who wish to pursue this direction. Because two years of experience with hospice and palliative care teams is required for this “grandfathering” option, physicians would need to start by the Spring 2010 in order to apply in Spring 2012 to sit for HPM boards in the Fall 2012.

“There is a shortage of HPM physicians for the number of programs we have today, and that need is going to grow rapidly,” says Loren Friedman, MD FAAHPM, Medical Director of the Palliative Care Service at Virginia Hospital Center in Arlington, VA, who chairs AAHPM’s Workforce Capacity Task Force. The task force projects a current need for 8,000 HPM physicians, double the number working in the field, with fewer than 200 new fellowship graduates each year.

“For our new field, there were limited opportunities for formal training in HPM in the early years. Initially, most of us switched to hospice and palliative care from some other medical specialty,” Dr. Friedman notes. “Things are different now. We have a large body of evidence-based medicine to define our field and we have fellowship-trained physicians. However, there are also mid-career physicians who have only recently developed an interest in hospice and palliative care. They have a level of life experience and professional expertise that is an asset to the field.”

For those physicians, the practice pathway option requires finding a hospice or palliative care program where they could accumulate HPM hours by working for the program and caring for its patients, either paid or unpaid, as part of a structured, part-time educational experience. The Palliative Care Service at University of Kansas Medical Center (KUMC), Kansas City, KS, includes two part-time faculty members who are not HPM board-certified but have shown an aptitude for the work, reports Karin Porter-Williamson, MD, section head for palliative medicine. KUMC also has two full-time HPM fellows and an extensive educational curriculum and Web-based learning portal already in place.

“What we’re doing here grew organically from the needs of my partners who do palliative medicine and from the fact that recruiting board-certified physicians has been very difficult for us. I wanted to take the people who were doing a good job and mentor them. It’s experiential cross training for people from other medical backgrounds,” in this case internal medicine, hospital medicine, and geriatrics, Dr. Porter-Williamson says. The two physicians are working toward qualifying for the boards in 2012 while attending palliative care interdisciplinary team meetings and serving as hospice physicians for appropriate patients discharged home.

“It’s been easier to operationalize the experience for internal people because they already have privileges at the medical center. A few doctors from outside the institution have come and shadowed us for a week, but haven’t gotten into our program. I actually tried to get privileges and a faculty appointment for one of them and couldn’t,” she says.

“Our goal is to help people work toward board certification, but how do you get your head around the experience that is required to become a good HPM physician—beyond just passing the test?” At KUMC, that experience includes both clinical and didactic components along with scholarship by attending a regional or national HPM conference, giving lectures to residents, and participating in a hospital quality improvement project. “The goal is to offer a well-rounded experience that creates practitioners who are good at the clinical and educational aspects of HPM.”

The fellowship program at KUMC collaborates with Kansas City Hospice & Palliative Care, which has found it easier to offer clinical opportunities to community physicians at its freestanding inpatient facility and in patients’ homes, along with didactic lectures and faculty supervision, without facing the academic barriers at KUMC, says medical director Ann Allegre, MD FACP FAAHPM. “But we have not found a good way to offer this experience on a hospital-based palliative care consult service, because of hospital privileging issues.” At least one community physician, an anesthesiologist, appears poised to complete the program at KCHPC and sit for the board exam within the window of opportunity.

Tina Smusz, MD MA MSPH, a palliative care physician at Carilion Clinic in rural Christiansburg, VA, has also received requests from local physicians wanting to get credit for hours. “I said join in and attend our weekly interdisciplinary team meeting. I didn’t get any takers.” For those physicians who don’t have first-hand experience with what a dedicated hospice or palliative care team does, it can be hard to understand the competence expected of a true HPM specialist,” Dr. Smusz says, and that is why an opportunity to work with an experienced team and mentor is such an important part of the practice pathway opportunity.

At an affiliate—Carilion Roanoke Medical Center—Dr. Smusz’s colleague, Dr. Christopher Piles, did get takers—physicians who now attend team meetings, see palliative care patients, and provide backup coverage for him. “That works well for hospitalists,” Smusz notes. “It’s certification that motivates physicians to approach us. But once they see the real requirements, you can see if they are serious.”

At the University of Massachusetts (UMASS) Medical School in Worcester, MA, an embryonic palliative care program has been growing through a learning community comprised of physicians, nurses, social workers, and other professionals within the healthcare system, according to Suzana Makowski, MD MMM FACP, the only full-time palliative medicine specialist on staff. “It’s not yet a formal interdisciplinary team, but this is a way for us to start building that culture.”

This group has monthly face-to-face meetings, complemented by online discussions, social networking tools, and interdisciplinary discussions of real cases. The program incorporates mindfulness practice and aims to attract a broad range of physician specialties to this learning community. A team retreat and online curriculum are planned for January 2010. UMass physicians interested in preparing for HPM boards can set aside time to make rounds with Dr. Makowski or use the work they are already doing in the medical center, supplemented with intensive study weeks at a palliative care training site, such as Harvard Medical School, Cambridge, MA, or San Diego Hospice and the Institute for Palliative Medicine, San Diego, CA.

Stephen Leedy, MD FAAHPM, chief medical officer of Tidewell Hospice in Sarasota, FL, says his agency was approached by several physicians in the community seeking HPM hours, and is now investigating the costs and benefits of offering a mini-fellowship program. “Our starting point was getting online and reviewing the board certification requirements. You need 800 hours of clinical involvement in the subspecialty-level practice of HPM, 100 hours of participation on a hospice interdisciplinary team, and caring for 50 terminally ill patients over two years,” he explains.

If physicians consistently attend an hourly interdisciplinary meeting every week and complete 8 hours of clinical involvement, they could meet the standard in one full day a week, 50 weeks a year, for two years. But it isn’t just a matter of hours, Dr. Leedy says. “We want people to actually succeed and pass the exam.” Tidewell would also want to give these physicians a real hospice experience, immersing them in the culture by working alongside experienced hospice nurses and other members of the interdisciplinary team, supplemented by a didactic curriculum via conference call or online. “We realized that time alone doesn’t get them to where they need to be.”

The Academy offers a number of resources to help physicians advance their skills in conjunction with a practice pathway experience, including the Clinical Scholars Program and the new Job Mart found on the AAHPM website. Dr. Leedy recommends to community physicians, “If you want to do something like this, make some noise with your local hospice or palliative care program. But be prepared to spend some time on it.”

For more information on how some programs are trying to offer practice pathway opportunities to help physicians in their communities to prepare for the HPM boards, contact Karin Porter-Williamson, MD, medical director for palliative care, Kansas University Medical Center, kporter-williamson@kumc.edu; Ann Allegre, MD FACP FAAHPM, medical director of Kansas City Hospice and Palliative Care, aallegre@kchospice.org; Tina Smusz, MD MA MSPH, palliative care physician with the Carilion Health System; Suzana Makowski, MD MMM FACP, palliative care physician at the University of Massachusetts Medical Center; and Stephen A. Leedy, MD FAAHPM, chief medical officer of Tidewell Hospice.

Pathway Certification Requirements
All physicians seeking eligibility will need to fulfill the following:
(*) at the time of application, hold a current certificate from one of the ten cosponsoring American Board of Medical Specialties or four American Osteopathic Association Boards
(*) demonstrate clinical competence in the care of patients
(*) hold a valid, unrestricted license to practice medicine in the United States or Canada
(*) pass the certification exam in hospice and palliative medicine.

Practice Pathway for Mid-Career Physicians
In addition to the general requirements mentioned above, physicians seeking certification through the practice pathway will need to complete either:
(*) Pathway A, which requires prior certification by the American Board of Hospice and Palliative Medicine with an expiration date of December 31, 2008, or later
(*) Pathway B, which requires at least two years and 800 hours of clinical involvement in subspecialty-level practice of hospice and palliative medicine during the five years prior to application including.
(*) At least 100 hours of participation with a hospice or palliative care team
(*) Active care of at least 50 terminally ill patients (25 for pediatrics).

Training Pathway
Physicians seeking certification through the training pathway will need to complete a 12-month hospice and palliative medicine fellowship training experience. The program must be consistent with guidelines established by the Accreditation Council for Graduate Medical Education.

For more information on specific requirements for certification, visit the website of the primary board by which you are certified.

ReachMD Partnership Sounds Like a Success

Have you heard yet that AAHPM has partnered with ReachMD, an innovative communications company, providing thought-provoking medical news and information to healthcare practitioners? More importantly, have you listened?

Established to help increasingly time-constrained medical providers stay abreast of new research, treatment protocols and continuing education requirements, ReachMD delivers innovative and informative radio programming via XM Satellite Radio Channel 160 and online streaming developed by doctors for doctors.

The Perspectives in Palliative Medicine series has been a huge success. With over 650 people downloading shows and others listening at home or in their cars, so many are tuning in to hear about key issues in palliative care. The latest programs,, hosted by AAHPM Executive Vice President Porter Storey, MD, include :

The Challenges to Pain Management in Geriatric Patients – 04/12/2010, with R. Sean Morrison, MD
Religious Issues Affecting End of Life Care – 04/05/2010, with Richard Payne, MD
Palliative Care’s Role in Treatment of the Seriously Ill - 03/29/2010 with Russell K. Portenoy, MD
Warning Shot: How to Deliver Difficult News – 03/22/2010, with Gail Austin Cooney, MD.
We are proud of our members who have done such a wonderful job representing the profession. If you haven’t listened yet, check it out, if you have, share your thoughts with us!

Jen Fuhrman
e-Marketing Manager

AAHPM

Assembly Recap at a Glance…

In a matter of one week, the John B. Hynes Convention Center in Boston transformed from a few rolled up carpets, posters, and chairs to a convention center full of energy, information, and more than 2,400 hospice and palliative medicine professionals. Tweets using the #AAHPM or #HPMAssembly hash tag numbered at 834, AAHPM’s blog team posted 28 blog posts during the Assembly, and the blog received views from 37 states and 10 countries. In addition to the many outstanding educational sessions, this year’s meeting featured a number of new programs, including a book club, medical & nursing student forum, and additional initiatives to be green. Please enjoy the following photos from AAHPM’s largest Annual Assembly yet. Click on the photo to enlarge.

We’re thankful for all of you who attended and contributed to the success of the meeting, and we look forward to planning an exciting 2011 meeting in Vancouver, Canada!

The AAHPM Resource Center, ready for opening reception attendees Wednesday!

New members and board members alike socialized Wednesday during the New Member Reception

President Elect Ron Crossno proudly marks his connection from Texas to Boston

About 30-35 medical students had the opportunity to learn about the field from HPM leaders during the first-ever medical student forum on Saturday

Outgoing President Gail Austin Cooney addresses plenary attendees Saturday morning


Many thanks go out to the AAHPM & HPNA Program Chairs, Daniel Fischberg (left) and Patrick Coyne (right).

More than 120 people attended a book club session Saturday to discuss the implications of Drew Faust's This Republic of Suffering in their practice.

Thanks for a great time in Boston. We'll see you next year in Vancouver!

Two competing public health crises: the undertreatment of pain AND the increase in opioid related deaths

We as hospice and palliative medicine professionals have been largely focused on the former public health crisis in our training and practice as well as research endeavors to improve pain assessment and management. The FDA has expanded authority given in 2007 to focus attention on the public saftey issues related to the significant increase in opioid related deaths. BOTH issues SHOULD be of concern to hospice and pallaitive medicine professionals. Our efforts this past year have been focused on both informing our members about the public safety concerns, while at the same time increasing the communication and collaboration with various federal agencies – particularly the FDA – regarding access, availability, and supply of a) pain management professionals, b) pain medications, and c) pharmacies that can dispense pain preseciptions. The Academy and its members must take an active role in the coming months to ensure vigorous dialog on this topic within the Academy, across other stakeholder groups, and to federal agencies. I look forward to working to facilitate this dialog in the coming weeks and months.

-Cameron Muir, MD

Preconference Workshop – Challenging Medication Management Issues at the End of Life

Henry the County Extension Agent was making the rounds of the feed stores when he ran into one of the local ranchers he hadn’t seen in a while. “Say, Jake,” he said, “I’m hosting a seminar next week over at the Grange and one of the experts from down at the University is coming in to talk about some new ideas that’ll surely make you a better rancher. Think I can count on you to attend?”
Jake paused a moment before he gave his thoughtful reply. “Not sure it wouldn’t just be a waste of time – I already ranch just about half as good as I know how.”
Perhaps in our more cynical moments we all feel a little bit like Jake. If you’re attending the Conference this week, then congratulations for bucking complacency. If not – well, we miss you.

I’ve always viewed the preconference workshops as a justifiable luxury. Some, like this morning’s ‘Building Effective Hospice and Palliative Care Teams,’ are just downright fun; others, like this afternoon’s ‘Challenging Medication Management Issues at the End of Life’ are considerably more academic. Unfortunately, the lack of access to handouts (they weren’t yet online at the time of the presentation) brings with it a difficult choice — listen carefully and pick up what gems you can, or scribe furiously, trying to get down data (and risk losing concepts.)

Anyhow, here are a few concepts that I extracted from the afternoon:

Drug-drug interaction effects can mimic imminent death (so can severe constipation). Elderly patients and those with organ failure have a combination of homeostenosis and a much narrower therapeutic range for many medications.
Interactions can be a result of either pharmacokinetics (CYP-inducers, e.g.) or pharmacodynamic.
Antihistamines (among a huge number of other medication classes) induce constipation. (Another reason for those of us sufffering from seasonal allergies to be miserable.) Hey, diphenhydramine lowers the seizure threshold, too.
PCA studies have shown that there is a 40-fold variation in need for opiates in post-op pain among individuals, all other things being equal. (But you probably wouldn’t get away with ordering ‘morphine 2-80 mg IV q 4 hours’.) Dose ranges are subject to interpretation by the nurse in any event, and there is no evidence that range orders really work to control pain. Consider something like ‘2 mg for pain less than 5 and 4 mg for pain greater than 5′.
Patients on multiple opiates pose a special challenge, but usually provide an opportunity for simplication. Do err on the side of lower in the case of long-acting opiates, and provide plenty of prn meds for breakthrough. Then reassess after a few days and consider adjustments in doses of long-acting agents.

—breaking news— The slides have just appeared online with two more
presentations to go. Better late than never?

Picking up again…
Methadone is a great drug for analgesia, but interactions with other medications are a big concern. QTc prolongation is also a concern, and attention should be paid to cardiac history and family history of sudden death.
Olanzapine works for nausea. (I did not know that…)
In nursing homes the abbreviation prn may mean ‘patient receives nothing.’ (I’ve never heard that one before.)
Changing a patient from another opiate to methadone requires a non-linear conversion. There are a number of different protocols which work, but the hallmark of any is that the patient be closely monitored during the transition, since respiratory depression may develop out of proportion to the analgesic effect. Adjustments more often than q 5-7 days probably have more potential for harm than good, so be sure that there is a reasonable breakthrough pain control strategy (prn methadone if in a closely monitored setting, otherwise prn narcotic of choice.)

All in all a great summary of some pharmacological concepts that I haven’t explicitly considered in some time. I’ve picked up a couple of new approaches to add to my pharmacologic armamentarium, and each time I hear the methadone pep talk I get a little more comfortable with a medication that I still treat with great respect. Maybe when I get home I’ll be able to practice a little more than half as good as I know how.

Michael Moffitt, MD, PhD
Scott & White Hospice
Temple, TX
mmoffitt@swmail.sw.org