Annual Assembly

Just One More Degree

You’re Not Just a Doctor Anymore: The New Art of Leadership is a pre-conference workshop I had the pleasure to attend. Everything you didn’t learn in medical and nursing school you learn from Kevin O’Connor, is how it all
started. Mr. O’Conner led with a metaphor that informed and shaped the content for 5 hour session. “What a difference a degree makes! From 211 to 212, water goes from being hot to powering a train. What matters if we add an extra degree to what we do everyday? That email, conversation, or phone call…just one more degree.:”

Mr. O’Conner offered a practical approach and a reframing of mindfulness to our roles as leaders in the organizations we all serve. Not surprisingly the entire session was about relationships.

The Extra Degree Starts Here

These are my take home notes, not to be place in a folder in a box in the basement. Rather these are action points to be incorporated in my daily life and shared in this blog for others who may have like interest in this practical approach to a reframed leadership mindfulness to our own relationships and social styles; personal or professional.
1. Paraphrase as a first response. Shine your light on the other person.
2. Consider questions first before conclusions.
3. Encourage: Affirm what you heard that you liked: You know what I like about what you said… Remember you can build a fire on embers……..focus on their pilot light and perhaps it will glow more
4. Link and connect with the word “and” and not “but”. I also avoid the word “just”.
5. Respond with a thank you or a paraphrase
6. Ask and listen…..everyone loves hearing a good listener
7. Listen in meetings, pause, summarize the content and add in a new thought
8. Know, understand and align with the language of other social styles.
9. Think about the product of the product. The obvious product from the American Girl store is the doll. The
product of the product for the parent is the day of memory making with their daughter. What is the product
of the product of a palliative care consult?
10. Use emotional narrative to get around the prevailing winds of organizational talking points.
11. Demonstrate interest, support and encouragement in others.
12. Be a student and not a teacher.

This workshop has been a transformative experience that lends itself well to the practical implementation in my daily work. I welcome comments and questions about the workshop.

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

Behind the Scenes: Setting the Stage for the AAHPM & HPNA Annual Assembly

Over the next few days, more than 2,400 physicians, nurses and other healthcare professionals will be descending upon “The Big Easy.” This doesn’t include exhibitors, guests and staff members who will also join us for all or some of the program.

Preparations for this conference starts more than a year in advance and onsite staging at the convention center begins days before the first attendees arrive.

So what goes on behind the scenes of the Annual Assembly? For the first time this year, a handful of AAHPM staff members will be snapping photos, sharing insights and perhaps revealing some “secrets” about how everything comes together.

I arrived on Monday afternoon with two of our exceptional “meeting planners” – Vanessa Mobley and Kelly Rostine – who plan, coordinate and oversee all of the logistics associated with the conference. This includes coordination with the hotels, convention center, caterers, registration management, a/v technicians decorators (that pipe, drape, stage and signage doesn’t just get there on its own!), hotel accommodations, receptions, concurrent and plenary rooms, exhibit hall set up and much more. The document that details all of the specification for the four day program is nearly 200 pages long. I often describe it as a “three ring circus” although truthfully, it’s more like a 12 ring circus since that’s how many educational sessions are taking place simultaneously most of the day.

Monday and Tuesday are mostly set-up days when staff begin arriving and unpack, along with the laborers, a/v and computer technicians and others responsible for setting up and supporting the conference. Here are some “behind the scene” photos of what things look like before everyone arrives. See you soon and travel safe!

Steve Smith, CAE
Executive Director/CEO
American Academy of Hospice and Palliative Medicine (AAHPM)

Follow me at @ssmithaahpm

Have you ever seen an exhibit hall before the booth and carpets are put into place? Not pretty. But it will be by Wednesday night!

The Great Hall of the New Orleans Earnest N. Morial Convention Center before it is transformed into the space that will host four dynamic plenary sessions.

Registration

New Orleans- Here we come

Soon over 2,400 people will be arriving in New Orleans for the AAHPM & HPNA Annual Assembly. While the attendees will be traveling to The Big Easy for the inspiring and captivating education sessions it would be hard to deny that many attendees are excited to get to explore the amazing city and all that it has to offer. The city is probably best known for the French Quarter, Bourbon Street, and the French Market (home of Café du Monde, famous for café au lait and beignets). The amazing architecture and many beautiful cemeteries are often attractions in themselves but most people equate New Orleans with food.

There are many dining options available so be sure to take advantage of the variety of restaurants to experience while in New Orleans. 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.

Below are the favorites from a few of our members. Are there other suggestions?

Restaurants-

Anything by John Besch- especially Luke, Domenica and the American Sector

Acme Oyster House

Arnaud’s (jacket suggested)

Central Grocery- Eat a Muffalatta

Clancy’s

Cochon and Cochon Butcher (for a sandwich or snack)

Commander’s Palace Restaurant

Deanie’s Restaurant- get the Seafood gumbo

Domilise’s Restaurant and Bar

Dooky Chase Restaurant

Drago’s Seafood Restaurant at Hilton New Orleans Riverside

Elizabeth’s Restaurant

Galatoire’s Restaurant (jacket required)

Gumbo Shop

Jacques-Imo’s Café

The Joint

K-Paul’s Louisiana Kitchen

Maurepas Foods

Mosca’s Restaurant

Mother’s

Mr. John’s Steakshouse

One Restaurant

Parkway Bakery & Tavern

Pascal’s Manale Restaurant

Redfish Grill

Ruth’s Chris Steak House

Willie Mae’s Scotch House

Treats-

Angelo Brocato- Ice Cream

Cafe Du Monde- café au lait and beignets

Praline Connection- Candy

Nightlife-

Bombay Club

Carousel Bar at the Monteleone Hotel- Lena Prima and her Band Friday and Saturday nights

d.b.a.

Maple Leaf Bar- Rebirth Brass Band Thursday nights

Rock ‘N’ Bowl

Sazerac Bar at the Roosevelt Hotel

Snug Harbor

Tipitina’s

Vaughn’s- don’t miss Kermit Ruffins on Thursdays (early show)

W.I.N.O.

Artists to check out-

Amanda Shaw & the Cute Guys

DJ Soul Sister- “The Queen of Vinyl,” Melissa Weber, is a double threat on Saturday nights, starting with her signature soul/funk/R&B show on WWOZ-FM. Then she loads her crates in the car and heads to Mimi’s in the Marigny, where she spins dance music upstairs into the wee hours. She’s back at Mimi’s on Sundays to put a chill-down exclamation point on the weekend.

Hot 8 Brass Band

Soul Rebels

Treme Brass Band

Dr. Michael White

Other attractions-

Le Monde Creole walking tour- offers unique views of many courtyards in the French Quarter that tourists generally do not get to see

Royal Street shops

World War II Museum

For more information on New Orleans, visit the CVB website.

Dual Diagnosis, aka Substance Abuse, Mental Illness, and Palliative Care

It seems innocuous, but the term ‘dual diagnosis’ describes a very complicated subset of patients — those who have a substance use disorder as well as a primary psychiatric disorder (anything from depression to schizophrenia). Throw a serious medical illness into the mix, and you have a recipe for one very overwhelmed palliative care physician.

Moving along, I’ve paraphrased key info from the case that was presented –

  • Presenters describing patient: “Opiate dependence, stopped methadone maintenance therapy, mood disorder, trauma history, cocaine, family estrangement, new cancer diagnosis.
  • Most of room: “This doesn’t sound good…”
Never fear, this patient is manageable! The most important thing is to recognize that a team approach is essential — involve psychiatry, social work, the patient’s outside providers, clinic staff, etc. Try proactive measures like a pain contract (though not infallible), and encourage the patient to bring her sources of support with her to appointments, whether they be friends or family.

  • Presenters: “Now she’s your patient and you’ve been noticing she’s missed a lot of appointments with you and her oncologist, she’s had a number of early pain med refills due to lost scripts and stolen meds, and she’s still having a lot of pain despite very high opioid doses. She refuses to switch over to methadone because she doesn’t like the side effects. Now what?”
  • Most of room: “Refer patient to someone else!”
    Wait! Let’s think about it first and consult with the interdisciplinary team. This is a patient who has had a long history of opioid addiction who is now back on opiates. Of course she’s going to fall back into addictive habits, so let’s figure ways to help the patient change some of those habits. But also don’t forget the phenomenon of pseudoaddiction, which is an iatrogenic syndrome of abnormal behavior that’s a direct consequence of inadequate pain relief.
    There are some strategies we can implement – prescribe only small amounts of opioids at a time, do pill counts, and get random urine drug screens (remember that standard UDS dont’t test for oxycodone, so you have to add that separately). Can we combine her psych/substance abuse counseling appointments with her already-scheduled palliative care appointments? And of course, ask the patient about her perception of the obstacles preventing her from full compliance (if you went to the Motivational Interviewing session, this is a perfect time to practice those skills).
    Now, say the patient is in remission, but still on high dose opiates due to continuing pain. Keep her on these? Since our ultimate goal is to manage pain while also optimizing function, we should probably wean her off the opioids. She’s wary of methadone, but lets explore those fears and discuss it with her substance abuse counselor. The addiction psychiatrist probably has some other ideas as well.
    This is the sort of patient who can be very trying yet ultimately very rewarding to work with. Though keep in mind that It’s especially important to have an outlet to vent the jumble of emotions that these patients stir up, which is another crucial function of the interdisciplinary team.
Erin Zahradnik, MD, Yale University Dept of Psychiatry

Driving Miss Daisy

You’ve all been there – the elderly couple shuffles into your office, peering through oversize glasses, slightly disoriented but helping each other out. Did you ever stop to think how they got to your office? They almost certainly drove – but should they? Shouldn’t it be their children’s job to tell them to stop?? Focus groups have shown that it’s the physician they look to for guidance (sigh).

Luckily, there are excellent resources to guide you in evaluating driving impairment and to let you know what the laws are in your state. Google “AMA older driver safety” for a wealth of information. It’s free and you don’t have to be an AMA member to access it. There are even disease-specific recommendations from areas as diverse as ophthalmology, cardiology, and neurology. The AMA also has an ethical opinion on impaired drivers and charges the physician with recommending driving restrictions and, if needed, reporting impaired drivers to the Department of Motor Vehicles (DMV).

Dr. Karen Cross recommends a 6-step approach. (1) Identify patients at risk of impaired driving; (2) find out if the patient is still driving; (3) assess their driving skills; (4) make recommendations with referral for a driving evaluation – try www.aded.net for resources; (5) counsel the patient about transportation alternatives; and (6) if all else fails, report the driver to the DMV.

A little more on identifying patients at risk of impaired driving. Driving requires vision, both peripheral and focal. It requires physical activity – from opening the car door to moving one’s foot from the gas to the brake. Reaction time is also important, along with memory and the ability to concentrate, especially when distracted. Many of these skills can be evaluated in the office or home setting. A driving evaluation may be useful when there is conflict over the patient’s abilities. Unfortunately, these are not covered by Medicare or most insurers and can be expensive.

Restricting a patient’s driving can be life altering, resulting in depression, social isolation, and impaired self-esteem. There’s even an increased risk of long-term-care placement if an elderly person can no longer drive to meet their daily needs. On the other hand, there is the risk of injury to themselves or others. It is a physician’s responsibility to make the tough call and recommend driving restrictions when they are needed. Remember to check the AMA website for state-specific tools to support your recommendations.

Safe driving!

Chemo in the last 2 weeks of life

Chemotherapy is a two-edged sword. As an oncology trainee I’ve seen a few patients die solely because of it. And yet aggressive treatment is sometimes necessary to save a life; in the right settings it often succeeds. Patients with Hodgkins’ disease, testicular cancer, acute leukemias, and early stage colon, lung, or breast cancers, among others, are often cured because of chemotherapy and other aggressive treatments. Like any useful tool though, it must be properly applied in order to be effective and avoid harm. You wouldn’t use a screwdriver to drive a nail; similarly, chemotherapy shouldn’t be given to all patients in all situations, nor should it be a substitute for good discussions about goals of care and the likelihood of deriving benefit.

Yesterday’s cancer SIG presentation cut to the core of many issues that create tension between oncologists and palliative care clinicians. Most of us have probably seen difficult situations involving chemotherapy; it can be very upsetting! We tend to point the finger at oncologists when things go wrong, but we must recognize their unique perspective. To paraphrase one of today’s presenters, “Sometimes I can give a patient 5 different rounds of chemotherapy over 7 years and see them respond well each time.” In other words, chemo often really helps patients, even when its intent is palliative. I promise, we’re not monsters….oncologists are people too! :)

Data support the use of chemotherapy in a number of advanced disease settings, even many solid tumors. Yes, chemotherapy can and should be part of good palliation in many settings. There are significant symptom benefits, QOL improvements, and survival benefits to be had in cases of lung, breast, colon, and prostate cancer; many other solid tumors respond to chemotherapy as well. Of course, the devil is in the details. An emerging quality indicator in oncology practice is the proportion of patients receiving chemotherapy in the last 2 weeks of life. Too many patients are receiving chemo just before death.

Here’s the conundrum: we know chemotherapy can be beneficial, but only in certain settings. Unfortunately we’re not very good at predicting how well a particular patient will tolerate treatment, nor how well their tumor(s) will respond. How should we proceed?

The SIG speakers recommend following a framework: First, look to published guidelines like those from the NCCN, which tell us when chemotherapy is no longer recommended (link). If treatment is pursued, it must be done with full informed consent regarding its palliative intent. Treatment must be viewed as a time-limited trial, with specific criteria for measuring response and planned discontinuation if none is seen. Transitions to hospice should be discussed early, at the first signs of decline in function. And the palliative care team should be involved! As Dr. Smith pointed out, recent data on early palliative care in advanced lung cancer shows a resultant reduction in chemotherapy usage in the last 60 days of life. We still don’t really know how this works, but it works, and it doesn’t impair survival.

Going forward, palliative care will become more integrated into comprehensive cancer care, as per recent recommendations (link). This requires palliative care clinicians to better understand the role of chemotherapy as part of good palliative care for many cancer patients. Let’s be constructive, and increasingly work side-by-side with our oncology colleagues in caring for patients with incurable cancer. Hug an oncologist today! :)

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

Concurrent Session – Delirium

Trust psychiatrists to give an afternoon session that makes you completely forget about that nap you were craving! “Delirium: A Study of Difficult Cases” consisted of 3 vignettes about various forms of delirium, complete with very realistic role playing and chock full of wisdom from palliative care psychiatrists.

First there was a case of reversible hyperactive delirium. We were reminded that just about anything could be the culprit behind it, including common HPM meds like opioids and benzodiazepines, minor infections, metabolic derangements, and overstimulating environments.

How to treat the agitation in reversible delirium? First try to reduce stimulation and create a soothing environment. Can you eliminate any unnecessary meds? AVOID benzos! Use 1st generation antipsychotics such as haloperidol or chlorpromazine (more sedating than haloperidol), and dose the way you would dose pain medications.

What about irreversible delirium? This is the kind that occurs during the dying process, so a good clue that it’s not reversible is that there will be physical signs of dying. In this case, you can use antipsychotics, but you could also use benzos like lorazepam or midazolam. Remember that the goal is to reduce suffering by reducing the agitation of delirium — this is NOT palliative sedation, this is medical managment of a medical symptom.

Sometime benzos won’t be effective, and in those rare cases you could try propofol or phenobarbital. The key point is to treat agitation like a breakthrough symptom.

The final vignette illustrated a case of mixed delirium in pediatric palliative care (complete with role playing where the parent was as much the patient as the kid). Yes, delirium happens in kids too! This is a sneakier form of delirium (and can happen in adults too) that presents with waxing/waning symptoms. The gist is that you treat kids the same as adults (though with lower doses) — haloperidol and risperdal (both antipsychotics) are effective and safe in kids and infants.

I left with the understanding that delirium is a form of suffering, and as patients who come out of it later say, is a terrifying and disorienting experience. Treat it proactively and don’t hesitate to consult psychiatry for tough cases!

Erin Zahradnik, MD, PGY-3 Yale University Dept of Psychiatry

“Bending the Cost Curve:” reflections on this morning’s plenary session

America, your bluff has been called…the verdict is in, and the old adage remains true: you cannot have your cake and eat it too (shocking news, I know). Clichéd as it may sound, that message rang true this morning as the annual assembly opened in a blaze of introspection and criticism of the status quo. The target? Rising healthcare costs. Even current levels of U.S. healthcare spending are unsustainable, yet we continue on a path of rising costs without adequate thought regarding the value of care provided.

The panel discussion featured Thomas Smith, Brad Stuart, and Rebecca Kirch, each presenting perspectives on the problem and fielding questions. Smith hit the nail on the head, pointing out that “value is missing, care is not optimal, and costs are rising unsustainably.” He highlighted some staggering statistics from a sample of cancer patients at a major academic medical center (Dy, et al, 2011). Roughly 1/3rd received chemotherapy within 2 weeks of death, ~25% ended up on a ventilator, less than 1/4th were discharged to hospice care, and ~1/3rd died in the hospital. Quite a sad state of affairs! Yet insurance premiums are rising quickly, having doubled between 2000 and 2010; herein lies the “missing value.” What are we buying with all this money spent? What’s a society to do?

At this point someone usually drops the “R-bomb,” which can curtail any meaningful debate. Imposing limits on healthcare is such a charged and seemingly un-American idea. Must rationing be the only solution though? Per Brad Stuart, the answer to this question is a resounding “no!” Stuart described a program called AIM (Advanced Illness Management), which effectively turns this debate on its head. Rather than focusing on imposing limits, AIM emphasizes the importance of eliciting and defining patient preferences early (and often), and facilitates doing this in the community rather than just the hospital. AIM data show how this approach can yield improved outcomes, higher quality of care, and even decreased costs!

This sounds like what many of us in palliative care already think we do; we’re communicators, goals elicitors, and compassionate caregivers. But we are handcuffed by a system that often views us as the alternative to aggressive treatments, especially in cancer care, and we’re often involved too late in the process. Thankfully, this too is changing. A recent guideline from the American Society of Clinical Oncology recommends early palliative care for all patients with advanced cancers (link). Palliative care is increasingly viewed as a part of the solution and a part of quality cancer care, rather than an adversary.

In this climate, 2012 is a time of enormous excitement for our field! How we brand and conduct ourselves though, is crucial. We must be partners in cancer care, not antagonists. As Kirch taught us in reviewing the CAPC report, how we talk about palliative care truly matters; if we do it “correctly,” patients are overwhelmingly interested in what we do, and would want it for their loved ones (link).

As a trainee in both oncology and palliative medicine, I cannot imagine a more exciting time to be working at the intersection of these fields. Let’s continue to work together to blaze a trail towards increasing quality of life and quality of cancer care. In line with the AIM program, and those like it, let’s be champions of patient choice, rather than reapers of grim. Palliate early, and often!

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

AAHPM pre-conference workshop: Junior faculty bootcamp

“Early Career Hospice and Palliative Medicine faculty Development Bootcamp”: Drs Bernacki, Carey, Sanchez-Reilly, Periyakoil, Kapo, DeLima Thomas, Morrison, and Bunch O’Neill

I was a little apprehensive about this workshop, since I’m still a fellow and not even junior faculty yet. I will be taking a faculty position when I finish my fellowship, so I figured that whatever I learn will still be applicable four months from now. I think many trainees wonder what it means to be an attending, and especially about the mysterious “non-clinical time” (which residents and fellows get just enough of to know that we probably want more of it!). I do know enough to know that it will be different than anything I’ve done so far, in terms of work-flow, responsibility, and expectations. To add to my uncertainty, I am joining our section as part of a significant expansion which will mean changes in how the entire section functions. I was hoping for some strategies to manage what feels at times to be a monumental task, and I was not disappointed.

We started by creating mission statements for ourselves: short, using active language, and focused on what we want to achieve and why. My mission statement: To improve medical care by expanding palliative care education at all levels. It was really inspiring to see how big we are dreaming! Other topics covered included time management (oh Covey square, where have you been all my life?) and conflict resolution (both in the context of patient interactions and with professional colleagues).

When we talk about interactions with patients and families, we often talk about being intentional in our approach, to be mindful and centered in order to function most effectively. What I am taking home from this workshop is a greater sense of intention as I start my career, with my specific goals in mind and a much greater awareness of my own strengths as a palliator and as a faculty member. I was also really struck by the obvious camaraderie between our presenters, and the strength they derived from having a peer mentoring group. At our table we had a wonderful group of people and it was both somewhat therapeutic and also really fun to share stories about challenges in each of our lives. It was really striking how the same themes kept coming up over and over again across the whole group. Take home message: it can be hard to be a junior faculty member, and what you’re going through is normal!

I walked out of the workshop focused on my goals, inspired to implement some of the tools we learned, and feeling more confident in my ability to shape my career to match my vision. I am really looking forward to the rest of the conference, meeting more new faces and getting more inspiration for what I already consider the greatest job there is.

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

Getting ready for 2012 AAHPM bookclub: help us pick next year’s book

Medical Humanities has played an important role in my personal development as a physician and palliative medicine doctor. Reading stories, novels, poetry, listening to music, looking at art and movies and plays have helped teach me

  • how to face suffering,
  • how to sit with it,
  • how to be curious about and wonder what will emerge if I stay long enough.

Two years ago, the humanities and spirituality SIG at AAHPM launched a book club – with Drew Dipin Faust’s The Republic of Suffering: Death and the American Civil War. This year, we followed with A. Verghese’s first novel, Cutting for Stone.

At the Academy meeting in Vancouver, we solicited proposals for next year’s book from people who attended the bookclub discussion. Instead of keeping the voting and selection to an insular group, we tapping into the emerging culture of “open access” and social media by opening the voting to the community at large – http://www.surveymonkey.com/s/2012_BookClub

To allow everyone time to read the book, we are selecting it early this year. The deadline for voting is coming up quickly. Please vote for your top 3 choices! While we will select the most voted for book for the Annual Assembly, the next most popular books will serve as topics for discussion for each season of the year.

Thanks for participating!

Suzana Makowski – Co-Chair: Humanities and Spirituality SIG