AAHPM Quarterly

In Her Own Words: VJ Periyakoil, MD, discusses IPE


Robert L. Jesse, MD PhD, is a strong proponent of interprofessional clinical and research collaboration and leads the VA Office of Academic Affiliations, the Nation’s largest provider of graduate medical education and a major contributor to health professions education and research. “Health care is a team sport,” said Dr. Jesse. “It is very important that multidisciplinary learners train together so that they can effectively work together to provide the highest quality care to all patients and their families.”

Approved in early 2002, the VA Interprofessional Fellowship Program is located at six sites across the country, with Palo Alto serving as the hub site.

“We currently have about 40 fellows nationwide: trainees in psychology, chaplaincy, nursing, and pharmacy who train side by side with medicine fellows,” said Dr. Periyakoil. “The intent of the program is to ensure that people don’t train in silos. Fellows or trainees learn to train together and have interprofessional, respectful dialogue so that later on [in their careers], it makes working together much easier. Moreover, the best way to provide quality patient care is to have multiple experts from various disciplines working together.”

Program Features
“Our faculty members—doctors, nurses, psychologists, social workers, and chaplains—meet on a regular basis to talk about what they need for all of our fellows. We are very deliberate in creating the training curriculum for this competency-based program. Together, our fellows and faculty meet for educational didactics and in-depth discussion.

“We also meet daily to discuss all the patients on service, with the physician fellow providing medical diagnoses and the psychology fellow assessing grief and depression and how it affects health. The social worker may point out the patient is homeless, and the chaplaincy fellow may assess how a patient feels about his or her faith. When you get multidisciplinary perspectives of patients, suddenly things come to life. [A picture emerges of] this full, living, breathing patient as a person who is a member of a family and of society.

“In addition to learning and working together, the IPE fellows conduct joint projects. For example, every Winter Quarterly, our IPE fellows collaboratively teach the Stanford undergraduates about the multiple facets of palliative care. We learn from our fellows, and the fellows learn from a multidisciplinary faculty. It becomes a gold standard of how we can practice much more collaboratively in the future.”

Challenges
“First, we know very little about how to train together. As a physician, if I’m left alone with several social work trainees, I have no idea how to train them other than with medical aspects. This area is really ripe for discovery and new innovation.

“Second, there is no dedicated funding to look at how to best train various disciplines together. We know how to provide interdisciplinary care, but we haven’t systematically studied how to teach interprofessional trainees concurrently without catering to the least common denominator.

“For example, we do a didactic on bereavement support, which is a topic that physicians know very little about. During the session, the social work fellows may be bored because they know it too well. How do you teach didactics and structure the curriculum in a way that we’re teaching to the highest, aspirational level for trainees of all disciplines? Likewise, to what extent do I need to teach psychologists, social workers, and chaplaincy fellows about opioids and pain management? Does it matter? If it becomes too deeply medical, it’s not really relevant, and if it is too superficial, a lot can get missed in terms of how to improve patient care.

“A gold standard is when all IPE fellows are taught at a level that is challenging to all of them in every single session. Once we figure out how to do that, the next step is to conduct research together so that we can advance quality of care.”

Beyond Palliative Care
“We practice palliative care within teams and groups; that’s not optional. How do we [share] that with other fields, such as cardiology and gastroenterology, where patients face similar challenges with fragmented care? If we systemically study what we are doing and talk in a standardized manner, other subspecialties will be eager to adopt and learn from palliative care. We have an opportunity to lead other medical subspecialties.

“Beyond that, we have a collective responsibility to mentor trainees in other disciplines. Just as team members in psychology, chaplaincy, social worker, occupational therapy, massage therapy, and music therapy are obligated to mentor the young physician trainee, an MD must support and mentor those trainees as well. By training fellows from all disciplines who practice palliative care, we can grow and innovate, and conduct research together.”

Future Plans
“There’s been a lot of interest recently within the VA to figure out what we need to do next. To me, the next natural step is for trainees to conduct research together. Right now this is a clinical fellowship, but interdisciplinary cross-pollination will open up opportunities for fascinating research in areas such as grief and depression and existential angst and pain.

“Beyond research, it’s important for the sake of all patients and families that we commit to a lifelong practice of working together.”

by Jane Martinsons, AAHPM senior writer

Call for Action: The IOM Report

Larry Beresford, freelance medical journalist in Alameda, CA (Twitter: @larryberesford)

The Institute of Medicine’s landmark new report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, developed with the active participation of several AAHPM leaders in an exhaustive, 2-year process of evidence-based deliberation, was released on September 17. It contains a number of key findings about the delivery of person-centered care, clinician-patient communication, professional education and development, and public education and engagement—many of which harmonize well with the Academy’s aims and activities.

In an article I wrote for the latest AAHPM Quarterly, board member Christian Sinclair, MD FAAHPM, states that every Academy committee, task force, and work group could use the IOM report as the basis for pursuing long-term goals in advocacy for the delivery of palliative care in America. Individual palliative care professionals, he hopes, won’t let this serious document “gather dust on the digital shelf,” but instead will use it to get the word out in their communities.

Read it, if not all 458 pages at least the six page summary of key findings and recommendations. Then, let us know how you find ways to use it as a tool for spreading the message of palliative care in the comments below.

Disparities, Diversity, and Palliative Care

Larry Beresford

We would like to think that hospice and palliative medicine are extremely patient-centered and individualized to the holistic needs and beliefs of each patient and family. But there can be widely differing perspectives across cultural groups about what individuals need in order to feel that their individuality was honored and what will be experienced as supportive and respectful care under the highly stressful circumstances of serious, advanced, or life-threatening illness.

Can the field of hospice and palliative medicine be more inclusive and more respectful of cultural and other differences than it already is? You can read more about the Academy’s efforts to advance these issues in the latest issue of the AAHPM Quarterly. AAHPM has empaneled a Diversity Advisory Group, which convened a “World Cafe” at the most recent AAHPM & HPNA Annual Assembly for attendees to discuss and prioritize these issues. The Academy has also developed an LGBT Special Interest Group.

What do you think? You can share your perspectives and suggestions on these vitally important issues below.

AAHPM Workforce Priorities

In June 2013 the AAHPM board approved the following priorities, including the addition of a senior level staff position fully dedicated to overseeing workforce, leadership, and academic initiatives for the Academy.

General

1. Addition of 1.0 FTE staff position (Director level) dedicated to workforce, leadership and Academic initiatives. One clear outcome of the workgroups is the recognition of the growing needs related to these areas. There is complexity with many stakeholders and much to gain with more Academy focus dedicated to workforce and leadership. This position would align one senior level staff person for each of the five strategic areas of AAHPM.

2. Assess and propose partnerships with other stakeholders (such as ASCO and AGS) to advocate for and promote educational innovations to address common workforce challenges, to partner on MOC activities, and to partner on data collection efforts.

3. Prioritize recommendations and develop implementation plan, timeline and clear delineation of assigned staff and committees.

4. Increase communication, information sharing and documentation related to certification requirements and fellowship training options with Academy leaders, members and between key contacts within external organizations.

5. Ensure ongoing workforce initiatives align with strategic plan goals and related governance structure.

6. Identify opportunities for increased engagement, collaboration and reporting regarding workforce issues and initiatives among Academy leadership (Board, SCC Chairs, senior staff and others).

Workforce Data & Health IT

7. Update existing workforce study with available projections (comprehensive study not necessary)

8. Conduct an assessment of currently available health information technology to increase clinical practice efficiency in HPM and meet regulatory expectations, including data collection and clinical decision support tools, as well as quality monitoring solutions. Conduct gap analysis and generate recommendations for new product development.

9. Identify data available in existing health information databases. Systematically review to ensure HPM inclusion

10. Gather information on post-fellowship trained physicians in order to track data and impact workforce

11. Enrich workforce information and practice data in AAHPM member profile/database, including if feasible and available, data from the 2010 salary survey

Maintenance of Certification and Alternative Pathways

Current Specialist Workforce

12. Provide effective member education about MOC, MOL, OCC including next steps

13. Develop two HPM MOC modules in at least three specialties (ABIM, ABFM, ABP) and ideally all 10; seek same with OCC. Sustain and grow the number of HPM subspecialists.

Generalist and Mid-Level Providers

14. Promote generalist level education to non-HPM specialists and mid-level practitioners including marketing of UNIPACS/Amplifire to hospitalists, geriatricians, emergency physicians, (for example) and mid-level providers.

Innovative Fellowship Models
15. Develop a document from AAHPM outlining the process and providing a template for obtaining the sponsoring board and the ACGME permission for an exception to allow a single individual to complete a fellowship half time over two years.

16. Propose to the ACGME a focused or full revision in program requirements to allow programs to organize to accommodate a fellow taking longer than 12 months, at less than full time. A focused revision would address ONLY the time taken to complete fellowship and allow less than full-time; a full revision would include the time element as well as a complete re-evaluation of fellowship requirements as is common with a new specialty after five years of review.

17. Work with the Veterans Administration to encourage the VA to develop, fund and implement an HPM fellowship structure geared to mid-career trainees that would meet the VA’s need for more certified HPM physicians.

18. Seek grant funding to develop and pilot innovative fellowship model as described in the workgroup charter.

19. Offer strategic and consultative guidance to mature hospices interested in developing or collaborating with fellowship programs. AAHPM role might range from suggesting opportunities (such as hospice providing salary support for medical directors seeking midcareer part time fellowship training) to technical assistance about meeting fellowship requirements.

The recommendations directly support Strategic Plan Goal B: Build Workforce & Leadership.
Objective 1: Monitor and address pertinent workforce metrics and gaps.

Objective 3: Increase exposure to hospice and palliative medicine through expanded training in all medical schools and within residency and fellowship programs.

Objective 4: Support the development of mechanisms and pathways for mid-career certification in hospice and palliative medicine.

Medical Marijuana: What Should Palliative Care Specialists Know?

by Chad D. Kollas, MD FACP FCLM FAAHPM

Read the full article from the summer issue of AAHPM Quarterly.

No matter where you live, if you’ve practiced palliative care long enough, one of your patients has asked you about medical marijuana. “Does it help pain? Does it help nausea or poor appetite? And, perhaps the scariest question for some of us, “Will you prescribe it for me?”

In a surprising move in November 2009, the American Medical Association changed its position on medical marijuana, calling for changes to encourage research about its potential benefits. Other influential medical specialty societies subsequently published similar position statements.

Intrigued by that trend, I co-presented a session about medical marijuana at the Academy’s 2011 Annual Assembly in Vancouver. Several attendees expressed interest in the topic and agreed that AAHPM should consider a position statement about medical marijuana. This article represents a written update of that presentation, and it revisits a controversial question: Should AAHPM consider creating a policy statement about medical marijuana?

AAHPM Quarterly Article Highlights Job Satisfaction in HPM

by Larry Beresford

Most hospice and palliative medicine (HPM) professionals have been asked, “How can you do this work? Isn’t it depressing?” Depressing, some folks assume, because so many of the patients die, even though it is often expected. And yet, the experiences of those in the field is, in many cases, just the opposite—many professionals in the field report feeling uplifted, gratified, and hopeful because of the difference they are able to make in the lives of patients and families. An article in the AAHPM Quarterly summarizes data from the Academy’s Physician Compensation and Benefits Survey—2010 Report, other recent research, and the personal experience of HPM physicians to conclude that this work can be extraordinarily satisfying.

As a hospice volunteer over much of the past three decades, I can confirm the personal satisfaction that comes from making a tangible contribution to patients’ quality of life at a critical time of life. But physicians working in HPM may have additional benefits and job satisfaction from the varied opportunities for team leadership, program development, teaching, and research. AAHPM’s survey documents the wide variety of roles, settings, and job titles encompassed by the field of hospice and palliative medicine.

Another resource that has compiled the personal and professional stories of 17 physicians working in hospice and palliative medicine is the HPM Practitioner, an online newsletter published by the DAI Consulting Group. Brought to the field by a wide variety of paths and interests, these committed HPM physicians detail a range of job titles, duties, and responsibilities. But in most cases, they say they can’t imagine doing anything else than their current work in this field.

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

What Is Palliative Care?

by Ruth Mugalian, Public Communications Inc.

Read the full article about defining palliative care in the Winter issue of The Quarterly.

When I talk about my work with hospice and palliative medicine specialists and why I enjoy it, I usually say something like this: “They’re doctors who take care of very sick patients. They relieve their symptoms and make them feel better.” It should be a communications professional’s dream. It’s simple, understandable and positive. There’s no esoteric medical jargon or complex technical language to translate into layman’s terms.

And yet, that simple, positive description doesn’t quite capture it.

Describing what hospice and palliative medicine specialists do is an evolving challenge, as evidenced by the many different ways the doctors explain their work. Unlike many other medical specialties, there’s no simple one- or two-word description, like “heart surgeon” or “cancer specialist.” “They relieve symptoms” is far too narrow, but also too broad. Don’t most doctors relieve symptoms? And, what about all the other care they provide: the help with decision making and navigating the system, the coordination of care, the support for families?

Just summarizing the breadth of care is challenging enough, but of course, there’s another challenge. The heart surgeon fixes the heart. The cancer specialist attacks the cancer. HPM doctors don’t cure. They provide the care that helps the surgeon and the oncologist cure, and that helps the patient endure the cure.

And sometimes there is no cure. That’s when the HPM’s role takes on special meaning and ironically and frustratingly gets twisted into something negative: they withhold care, give up on the patient, hasten death. Of course, the opposite is true. They stay on the job when others have no more to offer. They continue, or begin, providing care when others have stopped. They’re passionate about controlling pain. Snappy phrases are tempting: “They don’t cure, they care.” “They never stop caring,” “Helping you endure, with or without a cure.” They’re simple, understandable and positive, and they don’t quite capture it.

On Organ Donation and Patient Wishes

by Katie Macaluso, AAHPM Quarterly Managing Editor

If you’re a member of AAHPM, you should be spotting a copy of the fall issue of AAHPM Quarterly in your mailbox any day now (if it hasn’t arrived already). Pick up this issue to learn more about the 2012 Annual Assembly, certification deadlines, advocacy efforts, and where palliative care falls in the readmissions boom (a feature article by Larry Beresford).

One standout article in the fall issue is “A Lasting Gift: Organ Donation” by Lucille Marchand, MD BSN. In this Art of Caring column, Dr. Marchand discusses one patient’s struggle to plan for organ donation upon his death. The patient was diagnosed with end-stage amyotrophic lateral sclerosis (ALS) and hoped to find meaning in his early death through the gift of organ donation. As the patient and his hospice team worked to develop a plan that would allow for a comfortable death for him and the successful harvesting of organs, it became clear that too many risk factors might prevent organ donation from being a viable option for him. Read the full article here.

Helping patients achieve their final wishes is so important to all involved in the interdisciplinary team. Have you encountered a similar situation to this one? How was it resolved? Do you have advice for your colleagues in hospice and palliative medicine?