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NPCRC Foley Research Retreat Reflections

Thanks to the generosity of the AAHPM’s “Research Scholars Program,” I had the opportunity to attend last week’s annual Kathleen M. Foley Research Retreat of the National Palliative Care Research Center (NPCRC, www.npcrc.org). Each year this retreat brings together nearly one-hundred senior researchers, junior faculty, and trainees alike, in an environment built to encourage mentoring, collaboration, and networking within our growing field. Attendees include those who have received funding from the NPCRC, their mentors, and selected national leaders. The event clearly stands out as a manifestation of the NPCRC’s mission: to establish priorities for palliative care research and to develop a new generation of researchers in palliative medicine.

Several trusted mentors had previously told me that this is, hands down, THE best conference in our field, so my expectations were rather high even before arriving in beautiful Park City, Utah. Indeed, the surroundings were gorgeous, but my expectations were exceeded; it was actually the meeting experience itself that provided the most amazement and inspiration that week! Everywhere I looked I saw another giant in the field, yet everyone was interacting informally and collegially, talking about research project ideas, struggles with grant-writing and funding, issues in career-planning, and important areas of inquiry for the future.

I vividly remember the experience of attending my first AAHPM Annual Assembly, especially the remarkably empowering and exciting feeling of being surrounded by over 2,000 people who are similarly passionate about our field. The Foley Retreat engendered similar feelings for me, but did so in an even more personal way by nature of its smaller footprint and more interactive design. I made several new connections during the conference, re-connected with a few old friends, and gained new insights about the right path for me in the near future as I ponder difficult decisions about research and job opportunities for July. I cannot thank the Academy enough for the support to attend this remarkable event, and the NPCRC for the opportunity to take part in the remarkable 2-day program. In many ways, the experience was transformative!

I sincerely hope to be able to participate in this remarkable event again in the near future.

Thomas W. LeBlanc, M.D, M.A.
Fellow, Medical Oncology and Palliative Medicine
Duke University

Cambia Health Foundation honors palliative care pioneers

By Angela Hult, Cambia Health Foundation

“If we want to transform something as huge as health care, we have to think big. We need to change the way the people we love are dying.” –Ellen Goodman

That’s what Pulitzer Prize-winning columnist Ellen Goodman told the crowd at last week’s Cambia Health Foundation Sojourns Awards luncheon in Seattle. Goodman, who co-founded The Conversation Project, an initiative to encourage people to talk with their loved ones about their care preferences at end of life, gave the keynote address at the luncheon.

At the event, the Cambia Health Foundation honored five Northwest palliative care pioneers for their vision and innovation in the field of palliative and end-of-life care. Each of the individuals received a $50,000 Sojourns Award in recognition of their accomplishments and as an investment in their future work.

Through programs such as the Sojourns Awards, Cambia Health Foundation is committed to improving access to and quality of palliative care, recognizing and advancing leadership and innovation, and facilitating an open dialog about end-of-life issues. The foundation also provides grants to organizations working to advance palliative care in their communities.

2012 Sojourns Award Winners

  • Patricia Berry, Ph.D., APRN (Salt Lake City, Utah): Helping nurses learn how to manage a patient’s pain and provide top-notch end-of-life care is University of Utah nursing professor Dr. Berry’s specialty. She also helped found the first hospice in the Intermountain West.

  • John Forsyth, M.D. (Medford, Oregon): A pioneer in the field of palliative care and the founder of a coalition called Choosing Options, Honoring Options, Dr. Forsyth has spent the last four decades encouraging Southern Oregonians to talk about their wishes and preferences for end-of-life care.
  • Carolyn Nystrom, R.N. (Ketchum, Idaho): As the executive director of Hospice and Palliative Care of the Wood River Valley, Nystrom provides quality end-of-life care for rural Idahoans. Thanks in large part to her efforts, more than 90 percent of everyone who dies in Blaine County have the support of hospice care.
  • Darrell Owens, Ph.D., DNP, ARNP (Seattle, Washington): After observing serious gaps in care, Owens, the director of outpatient palliative care at UW Medicine’s Harborview Medical Center, launched one of the first clinics in the nation to combine primary and palliative care for low-income patients.
  • Kathy Perko, P.N.P. (Portland, Oregon): For the director of the pediatric palliative care program at OHSU Doernbecher Children’s Hospital, caring for seriously ill children is her calling. Perko is in the process of starting a pediatric palliative care telehealth program for seriously ill children in rural Oregon.

Do you know a person or organization deserving of a Sojourns Award? Nominations for the 2013 Sojourns Awards open on November 1, and close on March 1, 2013.

Angela Hult is the executive director of the Cambia Health Foundation. Learn more at www.cambiahealthfoundation.org or @CambiaHealthFdn on Twitter.

The Personal Caring Initiative: A Transformative Approach to Palliative Care in a Regional Medical Center

In a recent blog post I wrote about the Mayo Transform conference awarding The Personal Caring Initiative with an iSpot award to showcase our work in providing personalized care to seriously ill people and their loved ones. This initiative includes the development of a palliative care service line, however we have taken several deliberate steps to engage the community and region of our regional medical center. This blog post shares the premise and the strategies that have served to elevate The Personal Caring Initiative to a transformative approach to caring for seriously ill people in our communities. We have attempted to change care and culture.

Serious Illness is Changing
The people we are privileged to care for through the services of Mayo Clinic Health System are living with multiple serious illnesses within the communities we serve. Several studies have shown the current health care system is fractionated and inadequate to address the needs of persons and families dealing with serious life threatening illness. Palliative Medicine is the only board certified specialty whose sole aim is to as a team provide the care that seriously ill persons tell us they want, namely, personalized care.

The Future is Upon Us
In times of declining reimbursement, demands of quality care, and more ill people, we must partner with our community resources to transform the care of seriously ill people of our communities to achieve increased quality of life, provide low burden excellent care while at the same time being more efficient. Unlike any other medical teams caring for people with serious illness, palliative care, has the skill, role and time to care for people with serious illness and people who may be dying. In fact, people like you and me with lung cancer live better and longer when receiving palliative care in addition to oncology care from the time of diagnosis as compared to similar people only receiving oncology care. As a health system, how do we insure the availability of dedicated palliative care services and enrichment of palliative care skills of our health care professionals? How do we then transform our faith leaders, our attorneys, our medical colleagues and our educators in service of people and families in our community living with a serious illness?

The Road to Transformation
Committed to the care of our most frail and seriously ill patients and their families, the southwestern region of MCHS, has strategically introduced a paradigm shift in caring for seriously ill people and their families. We have
1. initiated a fully staffed and professionally trained palliative care team serving the region clinically, educationally, and scholarly.
2. established a regionally represented palliative care community consortium with key stakeholders from the communities within our communities; Business, Education, Faith, Long Term Care, Pharmacy, Volunteers, and Elder Care.
3. created a position of a palliative care director of community engagement to lead the consortium and build relationships with key stake holders region wide.
4. partnered Palliative Care and Development for Philanthropic support.
5. initiated an Advance Care Planning Online Resource Center launching with public forum viewings of the documentary Consider the Conversation
6. developed the Mayo Clinic Health System Palliative Care Specialty Council with guidance from national mentors.

October marks the second anniversary of The Personal Caring Initiative and we are delighted with the changes we are experiencing in our health system. The immediate future entails increasing clinical staffing to accommodate patient demand and additional community and region wide initiatives to improve the care of seriously ill people.

Cory Ingram, M.D.
Assistant Professor of Family and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Care
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

Lessons from Palliative Care informed the Creation of Whole Person Care at McGill

In 2011, our burgeoning palliative care team had the unique experience to spend a week learning from the palliative care teams of McGill University. During that week we learned about the Whole Person Care Program and subsequently invited the Director of Whole Person Care, Dr. Tom Hutchinson to Mayo Clinic to lead a workshop on Whole Person Care. It was my pleasure to interview Dr. Hutchinson about the Whole Person Care (WPC) program at McGill.

Cory: Please share with us, Dr. Hutchinson how the whole person care program at McGill got started.

Tom: This history is important because WPC grew out of an insight from Palliative Care that subjective quality of life (QOL) could improve at a time when people are objectively becoming more ill. That change to improved QOL during periods of worsening incurable illness is the process of healing.

Cory: Tell me more about the relationship of WPC to Palliative Care (PC).

Tom: What PC did in taking care of incurable people was that they rediscovered the process of healing. Dr. Mount and Dr. Kearney are largely responsible for this rediscovery.

In 1999, they set out to reincorporate the process of healing into the medical mandate. It had been lost track of. We need both the medical science and the healing relationship; whole person care. The approach has been through transforming our approach to training our medical students and faculty and our relationship with the people of Montreal.

We have two main approaches. First with medical students they have a mandatory WPC curriculum that aims at teaching them tactics to provide a space for healing. Our hope is that McGill is producing physicians better able to incorporate a healing approach into their medical practice. Courses in the existential aspects of medical care are taught and mindfulness and meditation are offered as vehicles to facilitate a healing presence.

We also train our faculty so that there is an environment that is receptive to a healing approach where students can grow and develop.

Students are partnered with their faculty mentor for a mentorship process called physician apprenticeship. There are six students for one faculty for the entirety of medical school. Burnout is a significant entity in medicine. We have started to teach mindfulness for self-care and presence with patients.

We have engaged the public as we recognize the yearning of the general public for WPC. They are essential allies in the promotion of WPC. To capture their interest we have developed two forums to explore healing. Firstly, we have developed a film series in which films illustrating the process of healing are viewed and a dialogue is held after the film. The films are well attended.

We also offer a seminar series with a similar purpose. These are invited lectures on topics like empathy, hope, or other topics related to WPC.

Cory: I understand you are going to expand your influence to host the first ever international congress on WPC starting in the fall of 2013.

Tom: That is right. This conference will be held every other year in Montreal. The focus of the conference is to address how we can change the medical mandate to incorporate WPC. This will be a full breadth academic conference to cover topics such as mindfulness, narrative medicine, and methodology to change systems to incorporate WPC in to the standard practice of medicine.

Cory: This last spring you edited the first textbook on WPC. Can you tell us about the book?

Tom: The book attempts to put together the contributors to WPC from McGill and around the globe. It attempts to develop through 18 chapters the concept of WPC from different aspects and approaches. It covers topics from genetics to medical teaching, and concludes on professionalism at McGill. The last chapter lifts the veil and peeks at the future of WPC as a renewed focus on the relationship between the doctor and the patient. That relationship has both an empathic component and includes medical expertise that the patient doesn’t have. Along with that is the mutual respectful relationship and mutual vulnerability to treat them as a whole human being.

I think this is going to happen because this is what doctors really want and why many went into medicine. And it is what patients really want. Medicine is more effective than ever before but somewhat less attractive due to the loss of the approach to healing. A rediscovery of what is important to doctor and patient and gives satisfaction to both parties within the relationship.

Cory: Since WPC grew from lessons learned from PC, how will WPC and PC relate to each other going forward?

Tom: PC remains the best model for WPC that we have. PC is important as an exemplar of WPC. There is a risk that PC may become a more fixing, curing discipline and forget the healing aspect. PC has to remain the model for healing. PC needs to represent WPC for the rest of medicine. PC is a new way of looking at medicine that can change the rest of medicine. It will have a strong relationship with WPC. PC is a beacon for a different type of care.

Cory: How does PC maintain their skill, role and time in the changing health care landscape?

Tom: Not a simple solution. The more we turn medicine into an enterprise that is financially driven and primarily an industrial model of efficiency and cost effectiveness this will be unhelpful for medical practice. What these approaches do is focus on products and forget the reasons for what we do. A model that focuses on efficiency has different effects that particularly may divert away from processes that lead to healing. There is a momentum to the industrial model.

After speaking with Dr. Hutchinson, I can’t help but wish my medical school had had a similar curriculum with attention to WPC. Fortunately, there are ongoing opportunities to learn from the wealth of experience at McGill. I hope to attend the 2013 first international conference on whole person care. I have already read the book and given a copy to each palliative care team at Mayo within the Midwest.

Cory Ingram, M.D.
Assistant Professor of Family Medicine and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Medicine
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

Discovering Relief in Our Own Grief

Formal training in self-care is relatively uncommon in most medical disciplines. Hospice and Palliative Medicine (HPM) specialty may be the exception. Grief if left unnamed can be a source of great pain, and as with any wound, if ignored, runs the risk of festering only to cause even greater discomfort and distress.

Granek et al published a revealing qualitative study earlier this year establishing patterns of grief responses to patient loss among oncologists as negatively impacting both their personal as well as professional lives1. Some of the impacts included worsened emotional irritability and exhaustion as well as the potential for altered patterns of care for future patients in an effort to shield themselves from further pain. Many study participants described their coping mechanisms as one of distancing and denial. Importantly, participants commented on their awareness of these impacts but had no access to altering their behaviors. In fact, several physicians stated this was the first they had ever spoken openly about these emotions due to the taboo of being unprofessional in the medical community.

Perhaps no different from traditional wound care, exploring the depths of grief, risking heightened pain temporarily in favor of providing optimal exposure, may allow for the greatest potential to heal. By actively creating dialogues with colleagues and openly expressing our feelings of connectedness to our patients and families, this acknowledged closeness and care becomes a natural path to grieving in a supportive environment. In fact, it may provide integrated self-care practices offering enhanced resilience and job satisfaction2.

An opportunity for culture change is at our doorstep. With the recent new policy statements issued from the American Society of Clinical Oncology calling for integrated palliative care from the time of advanced cancer diagnosis, and enhanced doctor-patient communication regarding end-of-life care3, an opening for HPM collaboration offering supportive coping and self-care strategies for oncologists is possible. In the past year at UCSF, a portion of our formal curriculum on self-care in the Division of Palliative Medicine has been piloted within the Medical Residency training program with very favorable feedback. We are now in the process of rolling out a program with the UCSF Division of Hematology and Oncology.

Acknowledging loss can take form in countless ways with varying degrees of time commitment. In addition to creating communal condolence cards for those we have served, the UCSF Division of Palliative Medicine has an annual Day of Remembering where families and clinicians come together and openly share stories of grief and love invariably mixed with tears and laughter. What would be possible if clinicians in all specialties were afforded an environment that embraced relationships with our patients with a natural response of grief at the time of loss? What is more human than acknowledging missing someone we have cared deeply for? Perhaps the promise of remembering our patients is the greatest hope we can offer.

References :
1 Granek, L et al. Arch Intern Med 2012,172(12):964-966
2 Mack JW and Smith, TJ. JCO August 1, 2012 vol. 30 no. 22 2715-2717
3 Smith, T.J. et al. JCO Published online before print February 6, 2012, doi: 10.1200/JCO.2011.38.5161

Dawn M. Gross MD, PhD
University of California, San Francisco
Department of Medicine/Division of Hospital Medicine/Palliative Care Service

HPM Workforce Scenarios 2022: Hoping for the Best; Preparing for the Worst

by Larry Beresford

The most comprehensive assessment of the hospice and palliative medicine (HPM) workforce shortage, conducted by Dale Lupu for AAHPM’s Workforce Task Force in 2010, estimated a gap of between 2,787 and 7,510 FTEs just to satisfy the current need for HPM physicians.[1] And that doesn’t count the coming tsunami of aging Baby Boomers with multiple chronic conditions—or the looming retirements of many of the field’s leaders and pioneers.

The current pipeline of new fellowship-trained HPM physicians adds fewer than 200 new specialists to the workforce each year—with structural constraints on its growth. After this year’s HPM board certification exam in October, the experiential pathway to board certification for mid-career physicians will come to an end. And that is why the Mid-Career Training Task Force convened 43 experts and leaders of the field at the Westin O’Hare Hotel in Chicago August 9 and 10 for a summit designed to grapple with the workforce dilemmas and consider possible future scenarios for this field.

Where is the field of HPM going? Will it continue to experience growth? What will be the impact of an anticipated 4,000 new board-certified HPM doctors following this year’s exam? How does HPM fit into the reforming health care system of medical homes and accountable care organizations? How might the field evolve, revise its focus or even change its name to keep up with those larger changes? Should the focus of AAHPM be narrowed or broadened? If there is a limited resource of HPM specialists, can primary care physicians be taught to play larger roles in providing primary-level palliative care to their patients? What about nurse practitioners and physician assistants? What are best practices in a world where there will never be enough HPM practitioners? What kinds of mid-career alternatives might be envisioned to the full-year, full-time fellowship that will be required for new HPM physicians starting in 2013?

These are the kinds of questions that were explored at the Workforce Summit. National leaders like Norman Kahn, MD, executive vice president, Council of Medical Specialty Societies; Clese Erikson, MPAff, director, AAMC Center for Workforce Studies; and William Iobst, MD, vice president of academic affairs, American Board of Internal Medicine, offered insights, hope and useful suggestions and believed that a mid-career solution was at least theoretically possible, working with ABMS and other specialty societies. But first, it is essential for AAHPM to clarify the need — both currently and in anticipation of future need — and craft a proposal.

Clement Bezold, PhD, founder and chairman of the Institute for Alternative Futures, served as a facilitator, helping participants to engage in future scenario planning, which he acknowledged is an uncertain process. “It’s not about prediction but preparation,” he explained. “Success is the degree to which your current thinking changes.” Participants in small groups explored four possible future scenarios for the field, with his charge: “If this is your future, step into it.”

Congratulations to Academy leaders including Workforce Summit co-chairs Amy Abernethy, MD FACP FAAHPM, David Weissman, MD, and Mid-Career Task Force Chair John Mulder, MD FAAHPM for organizing and framing such an important discussion.


[1]Lupu D. Estimate of current hospice and palliative medicine workforce shortage. Journal of Pain and Symptom Management 2010 Dec.; 40(6): 899-911.

Larry Beresford is a freelance medical writer from Oakland, CA, who specializes in hospice and palliative care issues.

Mayo Transform Conference: Calling Out the End of Life Elephant in the Room

Since 2009, The Center for Innovation at Mayo Clinic has hosted a unique blending of design and medical professionals to hold a 3 day dialogue, at a deeper level, on innovations that shape new ways of providing medical care with over 8 countries and 21 states represented. There are over 125 businesses in attendance. As an iSpot awardee for our transformative approach to Palliative Care known as The Personal Caring Initiative, I sat down with members of the Center of Innovation(CFI) at Mayo Clinic to talk about Transform 2012: The Conversation will Continue, September 9-11, Rochester, Minnesota.

Cory: First of all, thank you for the iSpot award, I am very grateful and humbled with this award. I am new to transform and I understand it is really cool. Perhaps you can share why “Transform” and why is it cool?

CFI: As a very small team over the last few years, the vision is for transforming the experience of healthcare and to disrupt the status quo. Transform brings in people from many disciplines from outside medicine to collaborate about new care deliver models. Transform is an environment for ideas and inspiration. At the core, Transform is reaching beyond medicine to understand health. It is described as a passionate, energetic, excited, and nontypical medical conference. It is in the space between medicine and design.


Cory:
I remember my mentor commenting that we can’t change health care by changing health care but rather, we have to mature our culture and transform our communities. I understand that this year Transform is calling out one elephant in the room that has been considered politically radioactive and a major source of misguided rhetoric in the media, namely, end-of-life care.


CFI:
Two elephants are being brought out; End of Life Care and Teenage Suicide. We hope the elephants that come storming out will allow us to look differently at other elephants in our institutions and culture. Michael Wolf, journalist, is a panelist on the Elephant in the Room speaking on his experience with his mother’s medical care as illustrated in his New York Magazine article, A Life Worth Ending. Dr. Satow, is speaking on Teenage Suicide and his creation of the Jed Foundation in honor of his son.


Cory:
Why end of life care? In fact, Mr. Wolf’s article was very controversial. It seems a bit risky?


CFI:
It is a risk. It is a testament to CFI to be a disrupter of the status quo. We pick things you wouldn’t expect. This will resonate with the personal connection of people within Transform. They have been through this. You want this to blend into the everyday fold of their life. Leslie Koch will speak on the Governors Island story as an example of the something unexpected and an extraordinarily novel and relevant approach to transformation.

Leslie Koch, President of The Trust for Governors Island, is using a very experimental planning model to re-design something very big. She is overseeing the planning, redevelopment and ongoing operation of the Governors Island transformation in New York Harbor. Under her leadership, the island has been a place for experimentation with the end goal of becoming a vibrant public space for New York. She is approaching this project very openly, transparently and using a very experimental model, essentially co-creating the redesign of this property with visitors and citizens of NYC; people that will use the park. Imagine if we approached transforming health care in such a way, or at a micro–level, transforming the Palliative Care model. Going to the users — the patients and family of receiving Palliative Care — to discover new and transformative approaches we can use to care for people and their families living with serious illness and possibly approaching the end of life. Approaches that we may never even have considered on our own. Ultimately creating a care model that provides greater value and better outcomes to the patient and family — much more than an office visit that we sandwich in between visits that can range from ingrown toenails and annual check-ups. The needs of the patient come first, and a holistic model is the healthiest for touching all palliative patients.


Cory:
I am getting the sense that Transform is more than the 3 day dialogue?


CFI:
What happens at Transform comes back to the CFI to help us understand things differently. Dr. LaRusso has been pioneering this to bring forth the best solutions. Transform is a continuous conversation and connections with attendees throughout the years. The narrative of attendees is that this is a non-traditional conference.

I think the excitement around new ideas and collaborations is a driving force around people wanting to come. They are not satisfied with the status quo and want to impact the lives of people. We are proud of weaving design into health care.

I am very proud to be allowed to participate in Transform 2012 as an iSpot recipient for our work on The Personal Caring Initiative. I envision The Personal Caring Initiative as a model of care that offers hope for our culture and our society as a paradigm shift towards comprehensive tender loving human to human care to our most frail among us affirming life, all of life, including the part called the end of life. It is my hope that there will be a connection created between the AAHPM and Transform to thoughtfully continue to mature and transform our culture, communities and delivery of the best care possible for seriously ill people and their families.

Cory Ingram, M.D.
Assistant Professor of Family Medicine and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Medicine
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

McGill to Host World Renowned Palliative Care Experts

This year McGill will host the 19th International Congress on Palliative Care(ICPC) founded by McGill’s Emeritus Professor and Father of Palliative Medicine in North America, Dr. Balfour Mount. The congress is chaired this year by Dr. Anna Towers. This conference represents the oldest conference in the field, and is led by Dr. Bernard Lapointe, Eric M. Flanders Chair in Palliative Medicine and Director of Palliative Care at McGill, with whom I spoke to better understand what attendees could expect from their pilgrimage to Montreal this October 9th-­12th.

Cory: Thank you or taking the time to talk with me about the International Congress on Palliative Care. What makes the ICPC so special?

Bernard: It is a continuation of the vision of Dr. Balfour Mount, who founded the first ICPC in 1976 featuring Elizabeth Kubler-­‐Ross, Dame Cecily Saunders and Dr. Mount himself. Secondly, the congress is truly international with over 60 countries and all continents represented all coming together to share their visions on PC. The conference is bilingual with presentations in French and English. Lastly, what sets this conference apart is that we dedicate time for interdisciplinary dialogue, questions, and interaction. We pride ourselves in providing a time rich learning environment that allows for presentation and dialogue. It is truly interdisciplinary, and offers the current status of international PC with 400 posters and 260 presenters from around the world.

This year particularly, we have special sessions on pharmacology, the arts and humanities, volunteers, and architecture. The congress remains the largest venue for pediatric palliative care with two full days dedicated to pediatrics for those interested.

Cory: In celebration of the 45th anniversary of St. Christopher’s Hospice, how are you intending on spotlighting St. Christopher’s?

Bernard: This year as well we will spotlight St. Christopher’s and their 45-­‐year anniversary. Most interesting, Dame Barbara Monroe will speak on the history and lessons learned at St. Christopher’s and provide a glimpse of the future of PC at St. Christopher’s. The design is that the spotlight will start with a plenary and then a series of workshops.

Cory: I can only imagine that another highlight from the conference will be the closing plenary from Dr. Balfour Mount, On Healing.

Bernard: This will be a fabulous presentation from Dr. Mount that will serve as an overview of his career and his contribution to Palliative Care. I am looking forward to attending the International Congress and from talking with Dr. Lapointe, I have visions of an experience that will connect with rich history of PC at McGill and St. Christopher’s at the same time showcasing the most recent developments in an international interdisciplinary forum. Not to forget, Montreal is a beautiful and delightful fall destination.

Cory Ingram, M.D.
Assistant Professor of Family and Palliative Medicine
Mayo Clinic, College of Medicine
Medical Director – Palliative Care
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

Preparing for the Board Exam- Test Taking Skills

Well, the board review course is complete and many of you are now beginning your studies in earnest. For many of you, it may be the first test you have taken in a number of years. While there is never a substitute for knowing the material, brushing up on your test-taking skills can give you that extra edge.


Bruce Chamberlain, MD has completed an excellent slide presentation on Test Taking Skills and Strategies for the HPM Board Exam. Some pointers include:

  • Never get “hung up” on one tough question. Skip it and come back to the question later. Sometimes later questions can provide hints to the answer.
  • Answer all of the questions. There is no penalty for guessing.
  • Always determine what the question is really asking. Don’t try to insert your “real world” experience.
  • With long questions, skip down to the actual question. This can help you focus your approach to the information.


The majority of questions are based on patient presentations occurring in settings that reflect current medical practice.


Remember. Take your time! What do they call the last person to leave the test with a passing score? Board Certified!


Good luck!

Vincent Vanston, MD FAAHPM

The Best Care Possible: A Conversation with Dr. Byock

In his new book, Dr. Byock shares his refined, crisp, socially and politically attractive call to action for people of our country to join in a thoughtful dialogue about how we all care for each through the end of life. The Best Care Possible follows The Four Things That Matter Most and Dying Well as a foundational contribution to Palliative Care and the American culture. Ira reframes the principles of palliative care in four simple words, The Best Care Possible. I spoke with my mentor about his new book.

Cory: I know you have been touring with your book, doing radio, television and press interviews. What is the dialogue you are hoping to incite?

Ira: The book is not the thing. I wrote the book to provoke discussion in the professional and general public about how we care for each other through the end of life. It is not from ill intention that people are dying badly, but rather because our culture doesn’t have a good sense of what good care is. Culturally we have to grow the rest of the way up. I want to feed the cultural imagination about what is possible through the end of life.

Cory:I want to ask a question that you likely haven’t been asked. As you taught me to state the obvious with patients and families, such as, “I want to make sure you receive the best care possible.” I can see your new book as a reframing of the principles of palliative care in four simple words, The Best Care Possible. I am interested to know how you would call the Academy to action to influence the national dialogue?

Ira: To the Academy’s members, I have to say that time is up. We have been talking for years about what needs to happen. We have been worried about what happens when the baby boomers approach the end of life. Now they have started to show up in the obituaries; 78 million of us. In medicine we have also created chronic illness with many people living with multiple serious illnesses.

I want the field to at least struggle with what is unfolding. Despite all the progress in hospice and palliative care, we are not ready. Look at all the technological advances in medicine, including the creation of the chronically critically ill patients….we are not ready. We have to rise to an unprecedented challenge to preserve western civilizations’ values of caring for each other and preserving the inherent dignity of each and every person as they approach the end of life.

The Academy has a leadership role in helping the culture grow the rest of the way up. There has to be a social and cultural transformation. We have to reframe illness and dying and the care throughout the end of life and reclaim caregiving through the end of life as a profoundly personal and only partially medical experience.

The Academy has to affirm the founding principles of the specialty. Physician-assisted suicide is one case in point. We can’t be neutral about the discipline’s stance. Physician assisted suicide and euthanasia are not the role of palliative care specialists. If you just think about it; we palliative care specialists are all pro-life. Preserving life is at the foundation of western civilization. That is why we have fire departments and police, to serve and protect. We have sanitation and clean water; these are pro-life parts of our society. To somehow allow a political movement to take that language from us and give it to those activists is far more power than they deserve. The Academy needs to start with affirming the principles of the discipline, the inherent dignity of people, the fact that we are pro-life, and that physician-assisted suicide is not part of medical practice.

The cultural transformation has to include being honest about preserving life and being honest about medical possibilities towards the end of life. As a culture we must recognize that we are mortal.

Branding what we do as providing “the best care possible” is consistent with enhancing quality of life, but has “social marketing” advantages. The boomers have always wanted the best. It is a simple message that works really well.

Cory: How is the Academy adopting this?

Ira: It is good language and messaging. In meeting new patients, I often say, “I want to give you the best care possible” as a way of framing the clinical relationship. The term is a vessel in which to pour individualized meaning. But the term is also effective in a social marketing. Giving and receiving “the best care” is meaningful individually and to the macro society. At all levels, palliative care is a way of delivering that goal.

After my conversation with Ira, I am doubly convinced that the best care possible isn’t a slogan or a sound bite. It is authentic. It cuts to the core of palliative care as we match medical possibilities to patient’s preferences and goals while managing symptoms, coordinating care with other medical providers, improving quality of life, providing a space for healing fractured relationships, fostering human development, honoring spiritual traditions and values, and baring witness to the bare and tender emotions of serious illness. Palliative care is the specialty that overflows the vessel of The Best Care Possible through the end of life. I thank Ira for his wisdom, vision and mentorship.

Cory Ingram, M.D.
Assistant Professor of Family and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director of Palliative Care
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System