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What to Do and Eat in Louisville

Over 1,200 people will be traveling to Louisville for the AAHPM Intensive Board Review Course, and the burning question on everyone’s mind is … where am I going to eat? Or is it… what am I going to do? Actually, with the packed schedule of educational sessions, food is more likely to be something of an afterthought. There are many dining options available beyond the nearest McDonald’s or room service, however, so be sure to take advantage of the amazing variety of restaurants to experience while in Louisville. With recommendations ranging from casual cafes to fine dining, several AAHPM members who are locals have graciously shared their favorite restaurants and attractions in the area.

So, where are you going to eat? Below are the favorites from our members.

American Cuisine:

The historic Brown and Seelbach hotels downtown have great food. The Hot Brown at the Brown Hotel is legendary and you can have cocktails in the lobby, where there is usually a pianist.

21C Museum Hotel restaurant, Proof

Jack Fry’s on Bardstown Rd is one member’s choice for the best restaurant to represent Louisville.

Hillbilly Tea Restaurant & Tea House

Decca

Bluegrass Brewing Company Brewery & Restaurant

Garage Bar

Rye

Ghyslain Bakery

The Blind Pig

Impelleizzeri’s Pizza

Wick’s Pizza Parlor

Bourbon’s Bistro

Café Lou Lou

Equus & Jack’s Lounge

Coal’s Artisan Pizza

Eddie Merlots

Jeff Ruby’s

Harvest

Lilly’s

The Silver Dollar Saloon

Great flavors from around the world:

Havana Rumba- Cuban

Mayan Café- Mayan food from the Yucatán peninsula

Seviche- Latin

el Mundo- Mexican

Sapparo- Sushi

The Irish Rover- Irish pub

La Coop- French Bistro

Majid’s- Middle Eastern

Simply Thai- Thai

Rami’s Café on the World- International Cuisine

Volare- Italian

Procini- Northern Italian

Veranese- Italian

Mozz Restaurant- Italian

Desserts & Sweets:

Please & Thank You

The Comfy Cow Ice Creamery

Sweet Surrender Dessert Café

Homemade Ice Cream & Pie Kitchen

Muth’s- make sure to try the toffee!

Things to do while you are in town:

July 13-15, 2012 is the 10th Anniversary of the Forecastle Festival. This three day Art and Music fest was ranked one of the Top 31 Coolest Tours and Festivals by Rolling Stone.

21C Museum Hotel was voted the #1 hotel in America and it has a contemporary art museum inside of it.

Visit the Louisville Slugger Museum and catch a game at Slugger Field, where the minor league Louisville Bats are playing at home. Then visit Against The Grain Restaurant & Brewery which is located at the Louisville Bats Baseball Stadium.

Tour the Kentucky Derby Museum at Churchill Downs

Stop by the Muhammad Ali Center and Frazier History Museum.

Waterfront Wednesdays are at the riverfront, are free and they feature live music.

The Kentucky Center is showing Circus Circus.

Catch an Indie film at Baxter Ave Theatre.

Take a stroll through the exhibits at the Kentucky Museum of Arts & Crafts.

The Vernon Club offers traditional bowling lanes.

Shopping-

The Bardstown Rd area is vibrant and young.

Frankfort Avenue is more family-oriented with ice cream shops, restaurants, and stores.

Nu Lu is very close to the Convention Center and is a must with eclectic shops and galleries.

Butchertown Market is home to a collection of shops that showcase the incomparable styles and flavors of Louisville.

For more information on all that Louisville has to offer visit the CVB website.

Comfort from a Robot?

by Jen Bose, AAHPM Coordinator, Marketing & Membership

After reading Last Moment Robot: ‘End of Life Detected’ I was a little torn. I didn’t know if I felt having a robot comfort me during the last hours or minutes of my life was creepy or really forward thinking and almost logical. As long as I can remember technology has been a huge part of my life and the lives of everyone around me. That part of me thought that the idea was pretty rational and that it makes complete sense. That is probably the same part of me that loved Terminator 2 as a child. Robots and computers have been integrated into everyday life and dying is part of that process. It seems like the next natural step.

While there is no replacement for genuine human interaction and compassion, I think the “last moment robot” would be oddly comforting to me. Perhaps my family couldn’t be with me because of timing or distance. I would want someone or something there with me. Is a robot that comforts you really that different from seeking the same comfort from a teddy bear or other stuffed animal? If given the choice between spending my last hours alone or with a robot that has been developed to mimic the comforting effect of another person I would take the robot. Would you?

The Why, How , What and “So What” of developing Clinical Informatics Tools

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

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

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

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

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

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

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

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

Diane Dietzen, MD Baystate Medical Center

Communication as a dance

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

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

Specifics:

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

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

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

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

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

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

palliative care and wellness

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

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

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

Themes:

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

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

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

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

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

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

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

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


Model for Running a Palliative Care Interdisciplinary Team Case Conference

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

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

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

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

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

REMS ARE COMING! – Comment before Dec 7!

It was a privilege to represent AAHPM at the fall meeting of the Council of Medical Specialty Societies in Washington D.C. on November 18 & 19, 2011. This was my first CMSS meeting and I was struck by the energy, collegiality, and nimble structure of this “society of medical societies.” There is no House of Delegates to debate everything like in the AMA – just a Board of Directors, Component Groups (CEO’s, Membership directors, clinical practice guideline developers, etc.) and occasional task forces. They have done a lot, but only taken a stand on 5 public topics – the most recent being support of comparative effectiveness research (in a letter the AAHPM signed).

I spent my time in a day-long seminar on the upcoming REMS – Risk Evaluation and Mitigation Strategy for long acting opioids. Regina Labelle, from the White House Office of National Drug Control Policy certainly got my attention when she explained that in 17 states, deaths from unintended drug overdoses now outnumber deaths from traffic accidents! Understandably Congress and the Administration want something done about this. Theresa Toigo, R.Ph., M.B.A., from the FDA explained that the Food and Drug Administration Amendments Act of 2007 (FDAAA) gave FDA the authority to require manufacturers to develop and implement a REMS when necessary to ensure the benefits of a drug or biological product outweigh its risks.

On April 19, 2011, in conjunction with the Office of National Drug Control Policy (ONDCP) release of the Obama Administration’s Epidemic: Responding to America’s Prescription Drug Abuse Crisis—a comprehensive action plan to address the national prescription drug abuse epidemic, FDA issued letters to application holders (makers and seller of opioids) directing them to submit a REMS within 120 days and describing the elements that needed to be included in the REMS (REMS notification letters).

So what is REMS and why should we care?

After notifying the makers and marketers of long-acting and extended-release (LA/ER) opioid drugs that they were required to submit a risk evaluation and mitigation strategy (REMS), FDA has been working with the sponsors that market these products on the required REMS. The central component of the Opioid REMS is an education program for prescribers (e.g., us) so that LA/ER opioid drugs can be prescribed and used safely. FDA expects the prescriber training to be conducted by accredited, independent continuing education (CE) providers (like AAHPM), without cost to the healthcare professionals, under unrestricted grants to accredited CE providers funded by the sponsors. Kate Regnier, M.A., M.B.A., from ACCME assured us that industry would not be dictating the curriculum so the CME can comply with ACCME standards.

What are they going to be teaching us?

On November 4, 2011, FDA announced the availability for public comment of a draft “Blueprint.” The Blueprint, developed by FDA with advice from other Federal agencies, is a basic outline and the core messages that FDA believes should be conveyed to prescribers in a basic two to three hour educational module. After it is completed and approved as part of the REMS, the Blueprint is posted on the FDA web site for use by CE providers in developing CE courses. The Blueprint for provider education can be found at

http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf

While, in general, I found these tenets reasonable, there isn’t a lot here about effective pain management for seriously ill patients. A few quotes will give you the flavor:

Health care professionals who prescribe extended-release (ER) and long-acting (LA) opioids are in a key position to balance the benefits of prescribing ER/LA opioids to treat pain against the risks of serious adverse outcomes including addiction, unintentional overdose, and death.

Prescribers should caution patients that ER/LA opioids can cause serious side effects that can lead to death.

Prescribers should explain that sharing ER/LA opioids with others may cause serious side effects including death, and that selling or giving away ER/LA opioids is against the law.

Prescribers should ensure that patients adhere to a treatment plan and monitor patients for misuse and abuse by

  • Recognizing aberrant behavior
  • Utilizing Prescription Drug Monitoring Programs to identify potential abuse where available
  • Understanding the role of drug testing and performing drug screens as indicated
  • Screening and referring for substance abuse treatment when indicated
  • Performing medication reconciliation at each visit

Whether this program will be required to maintain your DEA registration is being discussed. The REMS notification letters stated that although there is no mandatory requirement that prescribers take the course as a precondition to dispensing the medication to patients, application holders will be required to establish goals for the number of prescribers trained, collect the information about the number of prescribers who took the courses, and report the information to FDA as part of periodic required assessments. Although FDA recognizes that additional training modules could be helpful, FDA’s goal is to require basic education for all prescribers of long-acting and extended-release opioids, and at this time, FDA does not intend to develop or approve messages as part of the REMS beyond those approved in the basic core module.

Can we have any input into this?

We have until December 7 to submit comments on the draft Blueprint http://www.regulations.gov.

The AAHPM has been working with a group called CORE to develop a program that meets these criteria. Stay tuned for more about this.

AAHPM Calls on Washington (and you should be in touch with your local folk!)

Thoughts on Local Sausage-making and DC:

I spent an evening walking from the Washington Monument to the U.S. Capitol Building last week. Although the classic reference about legislation is “sausage-making” and something you don’t want to watch, I found the area by the capital buildings an especially peaceful spot to stop and admire the view of the reflecting pools projecting the mirrored image of our illuminated Capitol after a busy couple of days in DC. Despite all of the negative coverage about modern politics, the fact is that those working in DC are amazing, intelligent people. I couldn’t help but to be inspired by the promise that is the United States.

The AAHPM Public Policy committee held its second DC fly- in last week which proved a great chance to see DC in action. I was especially impressed by AAHPM’s policy team and its lobbying colleagues who are working hard to help represent all of us in Hospice and Palliative Care.

Perhaps you are thinking, the budget is a mess, health care reform is too controversial, and nothing can come of a DC visit?

To be honest, so did I. But I was wrong. The connections made this trip matter.

Sausage making in the Sinclair Lewis era was a disgusting mess and high risk, and I suppose that is why it was an apt metaphor for policy-making. Well, today I know my sausage makers, Patchwork Farms. They farm near me and I get their wares at my grocery. I know them and trust that what they produce is Missouri locally-raised pork that is high quality and raised in such a manner that is safe for my community.

And this is what is needed of you. You need to know your legislative representative and senators. (You can find them and e-mail them directly via AAHPM’s Legislative Action Center.)

Ask to meet them in your home town. Meet their health care aides.

And what do you say?

  1. Tell them who you are
  2. Explain what Palliative Medicine is. (I told the story of a rural gentleman that didn’t quality for hospice, but needed a good symptom control plan to help him achieve his key goal of avoiding hospitalization, and as a result he was able to go fishing and be at home when death came)
  3. Offer to be a resource for them locally
  4. Ask for support for the Palliative Care and Hospice Education and Training Act (read more about PCHETA here)
  5. Let them know of the bills that AAHPM supports (see link to AAHPM policy committee here)
  6. Make plans to stay in contact

Shouldn’t you know who is writing the laws that will determine the future of Hospice and Palliative Medicine and let your relationship help guide those future laws?

But do stay on target. Make sure you review the AAHPM policy site before your meeting, and if you get a question that you can’t answer just say so and promise to get back to them with an answer.

What I Learned from Visiting Academy Members

by Laura G. Davis, CAE, AAHPM Director of Marketing and Membership

I recently had the opportunity to travel out of Chicago and spend some time with Academy members. These visits gave me the opportunity to learn first-hand how our members spend their days. It was an enlightening experience. I spent time with Dan Maison, MD FAAHPM of Spectrum Health in Grand Rapids, MI, Sarah Friebert, MD FAAP FAAHPM of Akron Children’s Hospital in Akron, Ohio and Chuck Wellman, MD FAAHPM and Jeff Spiess, MD FAAHPM of Hospice of the Western Reserve in Cleveland, Ohio.

Here are my ten take-aways:

  1. Care comes in all shapes and sizes – golden retrievers and chinchillas make excellent pet therapists.
  2. When you’ve lived for 95 years, you can say what you want and tell the nurses and doctors what kind of care you want – and you get it.
  3. Every person should be treated with respect and dignity – even if you don’t agree with their healthcare decisions.
  4. Children are patients too and should have a say in their healthcare.
  5. Doctors and nurses can’t always “fix” you, but they can always make you feel better.
  6. How are you feeling? – the most important question you should be asked by your healthcare provider.
  7. Meditation, religion and spirituality are extremely important to patients and healthcare workers.
  8. Hospice touches all members of a family and those family members become volunteers.
  9. The government shouldn’t be making medical decisions.
  10. Hospice and palliative care professionals are special people with special gifts.

I am fortunate to work with such caring professionals.

Storyteaching as a way to enhance mutual understanding

Creative methods in Storyteaching, by Karen Bell, RN, Nancy Boutin, MD

Storyteaching is storytelling with a twist. Both are learned skills, as was aptly demonstrated by two gifted storytellers/teachers. There is one essential and several important structural hints, but the essential issue is setting; that is, a safe place where stories of immense personal importance can be told without time constraints and in a language familiar to the listeners. That means the storyteachers must take the time to know the patient/family life stories and use analogies and language from those stories to which they can readily relate. (Because “time” is an issue here, much of the hour was spent justifying storyteaching as an essential therapeutic intervention.)

Another important skill is the ability to tell the story with lots of holes in it. They call this “interpretative space”. If it’s a story patients/families can relate to, they will fill the holes with their own stuff, so that it indeed becomes their own and has much greater impact.

We were encouraged to develop a set of story templates dealing with difficult themes we encounter each day (e.g., CPR/DNR, AHN, the “When?” question, the use of opioids, etc.). The slides have many tips about this, are exceptional, and will be on the AAHPM website.
Charlie G.