by Chad D. Kollas, MD FACP FCLM FAAHPM—AAHPM Delegate to the AMA
The American Medical Association (AMA) held its Interim Meeting in a revitalized New Orleans from November 12-15, and AAHPM’s representatives enjoyed a productive meeting—while also partaking of Louisiana’s legendary cuisine! Alternate delegate Dennis Pacl, MD FACP, and I were pleased to welcome Patrick White, MD, AAHPM’s 2011-12 Delegate to the Resident and Fellow Section of the AMA, to our delegation. Dr. White is a palliative care fellow at the University of Pittsburgh, and he brought a wealth of youthful enthusiasm and the wisdom gained from his world travels to the proceedings of the AMA. Advocacy serves as the focus of the AMA’s Interim Meeting, and we enjoyed the good fortune of advancing several of the Academy’s key public policy priorities.
Reducing Prescription Drug Abuse
Meeting attendees awoke Nov. 14, to find the front page of their complimentary USA Today declaring, “Surge in Babies Addicted to Drugs.” The article dramatically underscored the urgency of one of the main issues addressed at the Interim Meeting — prescription drug abuse, including the increasing trend in deaths from opioid medications. The AAHPM delegation planned its strategy to advance Resolution 907, which called for the AMA to promote a variety of measures designed to address the problem. We secured support from the Pain and Palliative Medicine Specialty Section Council (PPMSSC) to offer testimony at live, on-site Reference Committee Hearings, where we emphasized the urgency of a response, noting that recent changes in state laws, such as Florida’s Statute 456.44, would impose new, strict rules on physicians prescribing controlled medications as early as January 2012. In the end, an amended resolution was adopted as AMA policy. It calls on the AMA to 1) promote physician education and training on controlled substances, 2) encourage screening of patients for drug misuse, 3) provide materials to physicians to promote treatment of their patients’ unhealthy behaviors, and 4) encourage physicians to use state prescription monitoring programs. The resolution’s sponsor offered gratitude to the Academy and PPMSSC for helping to advance the policy.
Visit with ONDCP Director
The Academy’s ongoing efforts to balance patients’ legitimate access to controlled medications while improving public safety received a big boost that was set up by AAHPM’s Capitol Hill Days in September 2011. This fly-in visit to Washington, DC, allowed AAHPM physicians and staff to meet with federal legislators and regulators to advance the Academy’s public policy priorities, including with Regina LaBelle, Policy Director for the Office of National Drug Control Policy (ONDCP). In follow up, AAHPM was able to secure a face-to-face meeting with ONDCP Director, R. Gil Kerlikowske. He was speaking at the AMA meeting as part of a panel discussion focused on the nation’s prescription drug abuse crisis .
We met directly with Kerlikowske and LaBelle for about 35 minutes to discuss the problem of prescription drug abuse. We helped them understand the special access needs of patients’ receiving palliative care while emphasizing the Academy’s ongoing commitment to patient and public safety. We discussed AAHPM’s collaborative efforts to prepare for prescriber education mandated by the opioid REMS, and we provided personal insights into providing palliative care in an increasingly challenging healthcare environment. Near the end of the meeting, we offered to serve as a resource for ONDCP in its effort to combat prescription drug abuse, and the directors both expressed genuine appreciation. They also accepted AAHPM’s offer to attend the Pain and Palliative Medicine Caucus Meeting, where they continued their positive discussion with AAHPM and PPMSSC members. This special opportunity will help to grow AAHPM’s relationship with another important federal regulatory body, very much in the way that the Academy’s relationship with FDA has evolved productively through the process of developing the opioid REMS.
Advance Care Planning
AAHPM’s delegation helped achieve adoption of Resolution 005, “Encouraging Standardized Advance Directive Forms Within States,” offering support in onsite hearings. The amended resolution was adopted by the AMA, and the Medical Student Section that sponsored it expressed gratitude to AAHPM for its support. Promoting advance care planning, like assuring patient access to medications used in palliative care, stands as one of the Academy’s public policy priorities. Successfully supporting Resolution 005 therefore furthered AAHPM’s policy goals, built upon existing AMA policies that help promote advance directives and advance care planning, and helps keep this issue in the public eye in a positive manner.
National Drug Shortages
The AMA plans to release a detailed report about national drug shortages, a problem that has profoundly affected palliative care specialists over the last several years. In the meantime, the AMA House passed a resolution that declares the issue of national drug shortages to be a “public health emergency.” This issue particularly resonated with colleagues from the American Society of Clinical Oncology (ASCO), who–like AAHPM–are members of the PPMSSC. The AAHPM Delegation will report on findings of the AMA study of national drug shortages when that information becomes available, which should be in June 2012.
by Patrick White
Patrick White is a Hospice and Palliative Medicine Fellow at the University of Pittsburgh and AAHPM’s delegate to the American Medical Association (AMA) Resident and Fellow Section.
Attending the American Medical Association (AMA) Interim Meeting in New Orleans was an amazing experience. From my first alligator sausage through our last meeting with the head of the White House Office of National Drug Control Policy, it was certainly one of the most entertaining and educational weeks of my fellowship. I was pleasantly surprised to see how many of the issues we discussed are relevant to my future career: from advocating for standardized advanced directive forms within states, to addressing shortages of crucial medications like morphine, to finding ways to reduce prescription drug abuse/misuse/diversion.
I was struck by how both my peers and the senior AMA delegates were interested in learning about how the hospice and palliative care community viewed the impact of pending legislation. I watched our own Chad Kollas chair the Pain and Palliative Medicine Specialty Section Council – a group encompassing 9 specialty organizations from addiction medicine to clinical oncology – advocating our positions on issues while building relationships with related specialties to further advance palliative medicine. The greatest highlight came when Jacqueline Kocinski, AAHPM Director of Health Policy and Government Relations, obtained a meeting with Gil Kerlikowske, Director of the White House Office of National Drug Control Policy. He was in New Orleans to address the AMA as part of a panel discussing prescription drug abuse. Our delegation discussed the unique concerns of palliative care and hospice physicians who frequently need to obtain schedule II opioids emergently for patients who are in acute pain crisis. Director Kerlikowske shared that he wanted additional input from AAHPM as new initiatives designed to stem the tide of opioid addiction and death move forward, helping to preserve our timely access to vital pain medications.
Observing the impact of these small meetings made me realize just what a huge impact groups like the AAHPM and AMA can have in shaping new health care policy. With so many crucial issues facing both palliative care and medicine as a whole, it is both an exciting and challenging time to be involved. I am grateful for the opportunity to see first-hand just how effective our voice can be and to work with people dedicated to advancing palliative medicine.
by Chad D. Kollas, MD, FACP, FCLM, FAAHPM – AAHPM Delegate to the AMA
While in Chicago from June 18-20 to represent the Academy at the Annual Meeting of the American Medical Association House of Delegates, my colleague Dennis Pacl, MD FAAP FACP – AAHPM’s alternate delegate – and I took in a show one night…. We saw Steve Martin and Martin Short at the historic Chicago Theater in what was billed as “A Very Stupid Conversation.” Now, I know that some question the continuing relevance of the AMA, but I would assure all AAHPM members that our time spent at the AMA Annual Meeting was anything but stupid. In fact, I am pleased to say that this gathering of physicians representing state and specialty medical societies featured some very thoughtful conversations, many that impact the future of medicine and a number that are key to our field.
I was honored to have been elected in November to chair the AMA’s Pain and Palliative Medicine Specialty Section Council (PPMSSC). As representatives of nine diverse specialties, the PPMSSC reviews the reports and resolutions before the House with implications for the pain and palliative medicine communities and decide where to provide testimony and offer joint endorsement or opposition. One resolution, sponsored by the Iowa delegation, called for a national dialogue by interested parties on end-of-life (EOL) counseling. AAHPM testified in favor of the resolution and identified the Academy and PPMSSC as interested in serving as resources in the endeavor. The AMA House of Delegates adopted the resolution as new AMA policy, and we’ll provide timely updates on the effort. Another resolution, sponsored by the American Thoracic Society, led to a recommendation that the “AMA encourage the Centers for Medicare and Medicaid Services to designate voluntary discussions about end-of-life care as covered services in the 2012 Medicare Physician Fee Schedule.” These efforts – which harmonize with the Academy’s policy priorities – build upon an opinion by the AMA Council on Ethical and Judicial Affairs approved by the AMA House in November 2010, which encouraged physicians to participate in advance care planning.
The AMA House also passed a resolution that called for reform of the Patient Protection and Affordable Care Act (PPACA). Although the PPACA contained many directives consistent with AMA policy, such as expanding health insurance coverage for Americans, it also contained provisions considered undesirable or controversial. The AMA specifically called for repeal of the Independent Payment Advisory Board (IPAB), enactment of comprehensive medical liability reform, studying further the Medicare Cost/Quality index and expanding the use of health savings accounts (HSAs). Support for individual responsibility for health insurance to cover the uninsured was also reaffirmed read more.
The House also accepted a report from CEJA regarding ethics rules guiding industry support for continuing medical education (CME). A representative from the Accreditation Council for Continuing Medical Education (ACCME) testified that the new ethics rules were consistent with current ACCME standards. AAHPM already conforms to both the ACCME standards and the new AMA standards, and also signed on to the Council of Medical Specialty Societies’ Code for Interactions with Companies.
Finally, some issues of interest to palliative care physicians were referred for further study by the AMA. The Florida Delegation sponsored a resolution asking the AMA to study the issue of national or regional drug shortages, a problem that has profoundly affected palliative care specialists over the last several years. Additionally, AAHPM supported studying the content of patient navigators programs to enhance their consistency. The AAHPM Delegation to the AMA will make the findings of the reports available to Academy members when that information becomes available.
Beyond the annual meeting, our collaboration with members of the PPMSSC continues. This summer, we’ll develop comments on a resolution addressing the right of access to medication for pain relief that will be presented later this year at the World Medical Association meeting. In the meantime, if there are issues that you believe we should take to the “House of Medicine,” I welcome your thoughts. I also hope that if you’re not an AMA member, you will consider joining? (be sure to specify HPM as your specialty if you do) – AAHPM’s representation and participation is dependent on having a sufficient number of Academy members among the AMA’s ranks.
by Emily Muse, AAHPM Manager, Communities and Programs
Saturday was the opening of the American Medical Association House of Delegates Annual Meeting 2011. One of the featured events was the eighth annual AMA-MSS Medical Specialty Showcase.
The American Academy of Hospice and Palliative Medicine was invited to exhibit at this event and took the opportunity to educate current medical students about the field of Hospice and Palliative Medicine.
Eager medical students visited booths exploring what options may be available to them. In narrowing down these career directions they asked a lot of questions, “Is HPM strictly for Family Medicine Residents ?”, “How long is a Fellowship in HPM? ”, “Can I practice HPM if I am a pediatrician?” , “What are the boards that sponsor this subspeciality” and “How many HPM fellowship programs are there?”. By the halfway point of the day I was “questioned out”! It was then that a young gentleman approached the booth. Before I could speak, he immediately introduced himself and said
“My Dad is a member of your organization, he just took the certification exam, I felt like I needed to stop by. I am not sure this is the right career path for me, but I know what a difference Palliative Care makes.”
It was so sincere and genuine, I almost asked if he would like to stay and work at the booth for the rest of the allotted time! While he moved on through the crowd investigating other medical specialties and subspecialties I was reminded that Hospice and Palliative Care is much more than the answers to the basic questions about fellowship. It is a philosophy of care that is driven by clinicians committed to patients as they navigate life limiting or life challenging conditions.
My name is Devon Fletcher. I’m a Hospice and Palliative Medicine Fellow at the Virginia Commonwealth University Health Systems in Richmond, VA.
I recently had the opportunity to attend the American Medical Association’s Interim Meeting in San Diego this November as the AMA’s first ever AAHPM representative to the Resident and Fellow Section (RFS).
I’d been fairly active in the Medical Student Section (MSS) of the AMA during medical school but after moving to a new place and trying to focus on residency it ended up being years since my last AMA meeting. When I heard about this opportunity to rejoin the AMA I jumped at the opportunity to be more involved in organized medicine again.
Going to these meetings can be a little daunting the first few times. Things move fast. There are a lot of acronyms and abbreviations that get thrown around about which I had to refresh my memory! There has to be a “game plan” going in. It’s like a bee hive: People coming and going, everyone on their own little mission for the good of the whole. As part of the RFS, as in the MSS, I was again impressed with the number of articulate, dedicated hard working young residents and fellows working to improve health care delivery for our patients and for the working conditions affecting physicians.
Elected delegates from the MSS and RFS bring forward opinions from these sections to the House of Delegates Meeting (HOD) a few days later. Even with my previous experience with the AMA, I was reminded at how vast the medical community is across the nation. Being able to participate in a national debate with opinions from a wide variety of physicians and providers from around the country is incredibly eye-opening experience. It is important to understanding the common issues we face as physicians and discussion concerning how we can face these problems as a group.
Of course there were plenty of educational opportunities including a session on advance care planning —which just so happened to be led by one of the doctors from my medical school training in Jackson, MS.
The RFS is split into “regions”. Regions 1-7 are basically geographic sections. Region 8 is the subspecialty section with representatives from many of the major medical subspecialty societies across the nation. Our specialty section would like to have a conference call/tele-meeting to just discuss the issues going on with each field … really just for our own education. If any AAHPM members have anything they want other fields to hear or know about hospice and palliative medicine or there are major topics you would like to bring up that affect our field, get in touch!
If you want to get involved for the upcoming meetings you could also apply for an At-large delegate position!
More on the AMA-RFS 2010 Interim Meeting.
AAHPM was one of 50 medical specialty organizations that exhibited at the recent American Medical Association Medical Specialty Showcase in Chicago. It was a great opportunity to talk about hospice and palliative medicine to the hundreds of medical students in attendance and also reassuring for us to see how many students were interested in the field and eager to learn how palliative doctors care for their patients. The Academy’s AMA Delegate Dr. Chad Kollas stopped by the booth to talk with the students and share his experiences and the path he took to palliative medicine. In fact, many of the students were familiar with hospice and had volunteered at their local hospice after one of their family members received hospice care. We encouraged them to continue to learn about the specialty by becoming student members of AAHPM.
Director, Marketing and Membership
The AAHPM Delegation to the American Medical Association (AMA) House of Delegates welcomed back a good friend and effective representative at the AMA’s 2010 Annual Meeting in Chicago, held June 12-15. Dennis S. Pacl, MD FACP – who was instrumental in the securing the Academy’s seat in the House and once served as its delegate – rejoined the team as Alternate Delegate, replacing Ron Crossno, MD CMD FAAFP FAAHPM, who is now focused on serving the Academy as its President Elect. I was pleased to accept the appointment to fulfill Dr. Crossno’s term on the AMA Pain and Palliative Medicine Specialty Section Council (PPMSSC) and will serve as Acting Vice-Chair through November 2010. Aided by key AAHPM staff – including CEO Steve Smith, Jackie Kocinski and Laura Davis – the Academy’s small, but effective delegation enjoyed another active and successful meeting.
Protecting and Expanding Past Achievements
The AMA periodically reviews established policies to ensure their relevance over time. After acceptance of its report on the ethics of palliative sedation to unconsciousness (AAHPM Bulletin, Summer 2008), the AMA’s Council on Ethical and Judicial Affairs (CEJA) planned to “sunset” an older policy that addressed decisions at the end of life. This older policy included concise definitions of key terms used in palliative care and clear statements about the ethics of withholding and withdrawing care outside of the realm of palliative sedation to unconsciousness. The AAHPM Delegation testified about the older policy’s enduring relevance, and the House of Delegates retained it as AMA policy in deference to the Academy’s continuing interest.
The AAHPM Delegation and PPMSSC also offered support to a passed resolution that asked the AMA to recognize, yet again, the benefit of hospice at the end of life and to encourage attending physician collaboration with hospice staff who are caring for their patients. This resolution will result in an AMA study of the Medicare Hospice Benefit and issues related to access issues for eligible patients. Your delegation expects the Academy will be involved in the development of this AMA report.
VA Physicians’ Access to Prescription Drug Monitoring Programs (PDMPs)
In April 2010, a member of the AAHPM Public Policy Committee brought forward for discussion a directive from the U.S. Department of Veterans Affairs (VA) Office of General Counsel (OGC) that restricted VA physicians from participating in state Prescription Drug Monitoring Programs (PDMPs). The OGC directive is based on concerns about patient privacy and informed consent issues inherent to PDMPs. At the AMA meeting, the Kentucky delegation introduced a resolution that opposed the OGC directive, which afforded a welcome opportunity for the AAHPM Delegation to advocate aggressively for Academy members who practice in VA hospitals.
In reference committee hearings, AAHPM testified in favor of Kentucky’s resolution based on three principles. First, the Academy argued that VA physicians should have access to the same prescription data as non-VA physicians as a matter of fairness and equity. Secondly, as evidenced by recent U.S. Food and Drug Administration (FDA) efforts to create a Risk Evaluation and Mitigation Strategy (REMS) for long-acting opioids, all physicians share a role in creating a balance between protecting patients’ legitimate access to controlled medications and assuring the public’s safety; PDMPs represent useful tools for achieving that balance. Finally, the AAHPM noted that while the OCG’s concerns about privacy and consent issues are prudent, they do not automatically trump issues of public safety, civil justice and professional autonomy from an ethical or legal standpoint.
Other Achievements in the AMA House
AAHPM co-sponsored a resolution with the American Geriatrics Society (AGS) and other specialty allies, urging the AMA to recognize an ongoing need for physicians who care for older adults to be competent in geriatric care and encouraging adequate geriatrics training in medical school and graduate education. This resolution passed with broad support, and it parallels Academy efforts to incorporate palliative care education into medical school and graduate curricula.
Lastly, through its involvement in the PPMSSC, AAHPM supported the acceptance of a report by the AMA Council on Science and Public Health (CSAPH) that addressed recent scientific findings on the pathogenesis of neuropathic pain. This included a recommendation for increasing the use of the term “maldynia” and integrating the objective concept of neural injury into the subjective experience of chronic neuropathic pain, a practice that would potentially benefit patients who suffer from disability related to neuropathic pain.
(Any AAHPM members interested in learning more about the work of AMA or joining the AMA should contact Chad Kollas, AMA Delegate, at email@example.com or Dennis Pacl, AMA Alternate Delegate at firstname.lastname@example.org.)