Resources

AAHPM Physician Compensation Survey Reveals Diversity in Pay, High Job Satisfaction

Charles V. (Chuck) Wellman, MD FAAHPM, is Chief Medical Director of Hospice of the Western Reserve in Cleveland, OH, and chair of AAHPM’s Leadership and Workforce Strategic Coordinating Committee

It is with great pleasure that we can finally announce the availability of the AAHPM Physician Compensation and Benefits Survey Report. Two years ago a poll of AAHPM’s members indicated a strong interest in such a survey. Earlier surveys, while helpful, suffered from a low rate of participation and from a lack of depth and refinement in the data. Consequently, the Academy’s Board of Directors charged the Business Practice Task Force to select a vendor who could help to design and implement such a survey. As a co-chair of the Task Force at the time and as current chair of our Leadership and Workforce Strategic Coordinating Committee, I can attest to the many hours that Task Force members spent on this process and the challenges we faced in dealing with the complexity and variability in our field.

The complexity is and will continue to be a challenge. HPM practitioners come from many different backgrounds. We work fulltime and part-time. We work for hospices, hospitals, the Veterans Administration, or as independent practitioners. Some of us are on salary while others have productivity-based compensation. We measure productivity in different ways. Some of us are in academic settings, and many of us have administrative, research, and teaching responsibilities. We have great variability in titles with no consistent agreement on chief medical officer, medical director, associate medical director, and team physician. As you might imagine, each iteration of the survey resulted in further discussion, and we realized a constant tension between designing a thorough, comprehensive survey versus a survey that might be too complex or time-consuming. In the end we find ourselves very pleased and grateful that nearly 800 of us were willing to complete this survey.

One will find that there is a wealth of data in this survey. It tells us a lot about who we are in this relatively young field. It will help to establish ranges of benefits and compensation, which will be increasingly important as we strive to attract residents and mid-career physicians to our field. The survey will give us greater flexibility in negotiating work hours, time off, productivity expectations, and CME benefits. There were also questions about job satisfaction, and it is exciting and gratifying to know 96% of us are satisfied or very satisfied with our profession and 93% of us are likely or very likely to recommend a career in HPM.

The survey will continue to be a work in progress. As we review the current survey results, it is expected that additional questions will arise, and there will be recommendations on how to further refine the survey questions. The unique and evolving arrangements in our field will challenge our future revisions, but we invite your feedback and encourage dialogue on how we can make future surveys more helpful and accurate. Comments can also be sent to the Academy at info@aahpm.org, (Subject: Comp Survey Feedback.) It is an exciting start.

NHPCO Management & Leadership Conference through Tweeter Eyes

I attended the NHPCO Conference and this year it was different. I’m a committed member of the tweeting subculture inspired by my twitter buddies after reading live commentary from sessions at the recent AAHPM conference in Canada.

I had not planned it before going to the conference but fell into it as I listened to the first session. My initial thoughts…..take notes in the form of tweets that I can review later. But with time and the growing joy in it, I embraced the mission to benefit to the bigger audience and resolved to tweet notes that others could follow, giving credit to the presenters & bringing the message to more people. I felt like a reporter bringing tales from the edge. I reveled at bringing the results of the Moran report to the twitter community, giving insight into the issues affecting the multigenerational hospice workforce, CMS’s recommendations about the Face to Face Visit regulations or bringing eAdvocacy strategies. It changed my conference experience completely. People around me asked what I was doing punching madly on my blackberry and became starry eyed at the thought of stardom in Twitterwood!

A highlight was meeting fellow tweeters. No introductions needed, we already know each other on a different level. I laugh as I approached them in hallways and at the bookstore “Hi!—– EOLnavigator. Great to finally meet you IRL (in real life). My real name —–Niamh!”

So what’s the point of tweeting live from a conference? Our collective mission is to get everybody passionate about end of life care with something to say about it online bringing their expertise to the masses and bringing the conference experience to non-attendees. I won’t miss another AAHPM conference & you can expect tweets on the road, not literally speaking! Read our tweets for the conference at www.tweetchat.com and enter #mlc11 hashtag or follow the #hpm hashtag to meet your online hospice and palliative care brothers and sisters.

JPSM Call for QI Papers Closes April 15

The Journal of Pain and Symptom Management is pleased to announce a call for papers that report the results of Quality Improvement initiatives in palliative care.

This publication of brief reports is a joint project of the American Academy of Hospice and Palliative Medicine and the National Hospice and Palliative Care Organization. Papers focusing on hospice and palliative care settings are encouraged.

The Journal offers this professional forum to encourage dialogue, peer review, and dissemination in response to a growing international concern about quality care, patient safety, and the role of evidence-based medicine. Submissions should describe specific Quality Improvement projects, such as efforts to increase pain screening, encourage goals discussions, promote palliative care consults, encourage earlier hospice referrals, or support staff well-being. Submissions must describe the impact of the intervention, either in terms of change over time or relative to a comparator.

Papers will be considered Brief Reports and must include the following:

1) A structured abstract of <150 words with five headings: Background, Measures, Intervention, Outcomes, Conclusions/Lessons Learned.

2) Five sections—Background, Measures, Intervention, Outcomes, Conclusions/Lessons learned—requiring no more than 1,250 words

3) No more than 10 references and two graphs or tables. (References/tables/ graphs are not included in the word count.)

4) A cover letter specifying that the Brief Report is being submitted in response to this Call for Papers.

Papers that fulfill the length and formatting requirements will undergo preliminary review by the Editors, and some will undergo external peer review. Acceptance for publication will depend on evaluation of the problem addressed, innovation, quality of the description, and clinical relevance of the intervention and outcomes.

Manuscripts submitted in response to this announcement should be submitted online to the Journal of Pain and Symptom Management (http://ees.elsevier.com/jps/) by April 15, 2011.

For questions regarding format or content of potential manuscripts, please contact Dr. David Casarett (Casarett@mail.med.upenn.edu).

MedPAC meeting in Washington on Palliative Care

I have always yearned for a Medicare Benefit for palliative care services, so it was with some excitement that I read an e-mail from MedPAC inviting me to a meeting in Washington March 23, to discuss palliative care.

The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 to advise the U.S. Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

The Commission staff invited a diverse group of palliative care specialists to come to Washington to discuss general issues such as the definitions and scope of non-hospice palliative care, the strength of the evidence that palliative care improves quality, outcomes, and service use, and factors that enable or hinder the delivery of palliative care.

The conference was attended by MedPAC staff, a moderator from the Lewin Group, and Janet Bull (Four Seasons, NC), Lyn Ceronsky(Fairview Services, Minneapolis), Timothy Keay (U Md Ca Center, Baltimore), Randall Krakauer (Aetna, NJ), James Lee (Everett Clinic, Washington), Diane Meier (CAPC , NY), Susan Mitchell (Harvard Aging Research, Boston), Michael Nisco (UC & Hospice, Fresno), Russell Portenoy (Beth Israel, NY), Greg Sachs (U of Indiana Aging Research, Indianapolis), Linda Todd (Hospice and PACE of Siouxland, Indiana), and myself.

It soon became clear that a new benefit for palliative care services is not on anyone’s drawing board, but the inclusion of palliative care services in new initiatives like Accountable Care Organizations, Community Health Teams to Support the Patient-Centered Medical Home, Hospital Value Based Purchasing, or Center for Medicare and Medicaid Innovation at the Center for Medicare Services is a possibility.

It was an energized discussion of wide-ranging aspects of our field, and we all hope the MedPAC staff can use what they learned from us to help Medicare beneficiaries with serious illnesses get the best possible care.

Porter Storey MD

Executive VP, AAHPM

Colorado Permanente Medical Group

Boulder, CO

Happy 100th Anniversary, PC-FACS

The 100th issue of PC-FACS, an AAHPM signature service, represents a milestone. Celebrating this century issue, Editor-in-Chief Amy Abernethy commented on trends in palliative care since the digest’s inception. Read the 100th issue of PC-FACS.

(1) Increasing acceptance of palliative care as a discipline. The palliative care philosophy now extends into diverse settings including mainstream medicine. Once identified with end-of-life care, palliative care now defines care delivered appropriately throughout complex life-threatening illnesses.

(2) Systematic development of an evidence base, and iterative refinement of a toolbox, for palliative care practice. Research now includes rigorous randomized controlled trials and systematic reviews as well as observational studies, and addresses a wide spectrum of clinical issues and outcomes ranging from quality of life to health service utilization.

(3) Basic science exploration. Complementing clinical studies, basic science can provide insights into, and a biological underpinning for, clinical observations. Bidirectional conversation between basic scientists and clinicians will help develop, evaluate, and refine the next generation of interventions, and continuously improve quality and outcomes.

(4) Examination of quality. Efforts to define quality will allow us to benchmark clinical practice, advance/improve standards, identify effective approaches, and disseminate best practices.

Palliative Care Grand Rounds 2.9

Welcome to the monthly edition of Palliative Care Grand Rounds the monthly review of the best of hospice and palliative care content from blogs. We started in February of 2009 and are almost done with our second full year. To see previous editions of Palliative Care Grand Rounds go the http://palliativecaregr.blogspot.com/.

Marten Creek Photo by Joan Robinson RN CHPN Seattle WA

This summer has been a exciting month for palliative care and hospice advocates. At the beginning of the month we were still taking in all the attention form Atul Gawande’s article in the New Yorker titled ‘Letting Go.‘ And then in the middle of August we had the ground breaking research published in the NEJM demonstrating early palliative care improves QOL, reduces depression and potentially can improve survival.

So I thought we could start with blog posts relating to those two big tent poles.

The Gawande Article

People were reflecting on the writing of Atul Gawande and I think there is a lot to learn from how he tells his stories. It may help in how you give a presentation or write articles or blog posts of your own. My favorite was a blog called ‘Not Exactly Rocket Science’, where blogger Ed Yong writes on ‘Deconstructing Gawande – why structure and narrative are important.’ Also check out Bob Wachter’s blog piece on Atul Gawande and the Art of Medical Writing. He writes:

In this month’s piece, Gawande continues to tackle the most important healthcare issues of our day. By doing this with such clarity and beauty, he makes us all a little smarter, wiser, and more sensitive. His writing is a gift.

Debra Bradley Ruder from the GrowthHouse blogs Goodbyes writes on the Gawande article as well.

The NEJM Study

Both Geripal (Alex Smith) and Pallimed (Lyle Fettig) jumped on the NEJM research quickly and provided really helpful insights into the research that you wouldn’t get just reading the New York Times or other media sources. Between these two posts there are currently over 35 comments! Several days later Drew Rosielle let the results marinate with him a bit and the result is a tasty dessert highlighting the implications for our field in his Pallimed post ‘You had me at improves HRQOL.’

Diane Meier jumped into blogging and wrote a good piece at the John Hartford Foundation blog, that was picked up my the (general medicine) Grand Rounds and got 2nd billing. Many other key blogs covered this as well including:

Other great bits

Each person faces cancer in his or her own way. There is nothing right or wrong about the different approaches people take. Denial or acceptance is not a statement about someone’s character. Having hope or not does not always come from an explicit decision to be hopeful; it often just happens one way or the other. Likewise, the spectrum from stoicism and strength to dependence and, yes, even weakness, are reactions that are unpredictable until you are actually faced with the disease. Too, how one feels can change over time — whether minute to minute, day to day, or year to year. So, one thing I have learned is not to be judgmental about how a person responds to cancer.

It is doubtful that a focus on reducing EOL spending per se will result in as much savings as is often assumed, for one simple reason: The concept of the last year of life is inherently retrospective. You do not know when the last year of someone’s life started until it ends. The stylized fact that leads to the assumption of wasteful EOL spending., i.e., 1 in 4 dollars spent on care in the last year of life, is based on an inherently retrospective concept that does not translate easily into the prospective decision-making that would be needed to reduce wasteful, futile or harmful spending in the last year of life.

And then I understood. I wasn’t crying for him. I was crying for me.

I cried because I couldn’t imagine a memorial service for me looking anything like the one for Rob. I cried because I couldn’t imagine that twenty people, let alone two hundred, would give up an evening to say nice things about me. I cried because I couldn’t imagine that my life, already a lot longer than Rob’s, would ever have that kind of meaning and impact. I understood then that my patient’s short life was telling me to live the rest of my own life better — to be warmer, and more open-hearted, and more loving.

people—actually mainly men—wished that they hadn’t worked so hard. They “deeply regretted spending so much of their lives on the treadmill of a work existence.” My wife would say that I work all the time, but I live a life where work and play are not easily distinguished. Is writing this work? It doesn’t feel like it to me. Tomorrow I’m off to give a talk at a science festival in the Austrian Alps. Is that work? The truth is that even in the most serious jobs I’ve always let the appealing (and often frivolous) come before the serious.

Some humor

Oscar the Cat - Photo by Stew Milne of AP.

So as you can see there are many people talking about the difficult things people don’t want to talk about. We are not alone in wanting to provide good quality care for patients and families facing with life-threatening illness. Sometimes with a little humor is a tough time, sometimes with fantastic insights into what it means to be alive. Go read and support the things that impact you with a comment, Facebook ‘like’ or email to a colleague.

Check out next month’s host the SWHPN blog called palliative-sw. They have a new look!

PCGR has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Day Two of Intensive Review…

The second day was just as intense as the first- fabulous speakers and a review of important information.
Here are some pearls from the second day of AAHPM board review course:

Dyspnea: (Vincent Jay Vanston)
-Total Dyspnea has 4 domains: Physical, Psychological, Interpersonal, Existential
-Must address all domains to adequately control Dyspnea
-When possible and appropriate, treat the underlying medical cause of dyspnea
-Opioids remain the front line agent for symptom relief
-Little support for benzo’s as front line agent
-Benzos and Opioids used together provide best effect when treating dyspnea

Nausea and Vomiting (Joseph Shega)
-Four pathways of Nausea- chemoreceptor, cortex, peripheral and vestibular
-No medications directly affect the Vomiting Center in the brain
-Know what drugs work on what receptors

Anorexia and Cachexia (Jennifer Reidy)
-Multiple factors contribute to ACS: tumor by-products, chronic inflammation, metabolic/neuroendrocrine/anabolic derangement
-Understand secondary causes of ACS (ex: oral problems, psychosocial issues, functional issues)
-ACS also occurs in non-cancer states such as with cardio-pulmonary disease, CKD, liver disease etc
-Understand difference between ACS and starvation
-Artificial Nutrition and Hydration (ANH) is not food, but medical therapy
-Purpose of ANH is not to improve comfort

Urgent Medical Conditions (Jennifer Reidy)
- Bowel Obstruction med management with analgesics, antiemetics and anticholinergics; anticholinergic drug of choice is glycopyrrolate 0.2mg-0.4mg sC Q6H or 0.02mg/hr infusion; drug of choice as it does not cross the BBB
-Spinal Cord Compression med management with high dose steriods; consider surgery +/- radiation therapy- good topic to look up in detail!!
- Seizures: status epilepticus defined as any seizure exceeding 5 minutes OR two seizures in 30 minutes without recover of consciousness- mortality 21-33%! those at risk: brain tumors, hemorrhagic stroke, h/o seizure, alzheimers, alcohol or drug abuse (w/d risk), liver/renal failure, lyte abnl, neurodegenerative dz, infections
-Seizure medical treatment options: subcut midazolam or phenobarbital; rectal diazepam (most antiepileptics can be given rectally); intramuscular lorazepam, midazolam or phenobarbital; sublingual lorazepam, clonazepam or midazolam; intranasal midazolam

Other topics discussed on day two: depression, delerium, other medical emergencies such as increased ICP/ pathological fractures and hemorrhage, palliative sedation, wound care, dementia, advanced cardiopulmonary disease and care of the imminently dying.

Suggested articles:

1. Abernathy A, Wheller J.Total Dyspnea. Current Opinions in Supportive and Palliative Care, 2008, 2:110-113
2. Del Fabbro E, et al. Symptom Control in Palliative Care- Par II: Cachexia/Anorexia and Fatigue. J Pall Med, 2006, Vol9 (2): 409-21
3. Ripamonti C, Mercandante S. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of Palliative Medicine, 3rd Edition. Doyle D, Hangs G, et al., eds. Oxford: Oxford University Press; 2003:8:496
4. Abrahm JL, Fanffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: “All I care about is walking and living my life.” JAMA 2008; 299(8):937-46
5. Stewart AF. Hypercalemia associated with cancer. N Engl J Med 2005;352:373-9
6. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Management 1995; 10:224-32
7. Wood, GJ, Shega JW, Lynch B, Von Roenn JH. Managemetn of intractable nausea and vomiting in patients at the end of life. JAMA 2006. 298 (10): 1196-1207

Other resources:

http://palliativedrugs.com website gives nice medication conversions

My thoughts on the final day at the review course will come shortly….

Tanya Stewart MD FAAHPM

Intensive Review Course is Intense!

Day one was an excellent and fast paced day in the dungeon of the Hyatt in downtown Chicago. It appears the leaders at AAHPM have mastered Atul Gwande’s “Checklist Manifesto” as everything appeared smooth from the start.

Over 680 participants and close to 300 on the waiting list; thirteen 30 minute sessions with two 30 minute panel discussions breaking up the day; 7 speakers… really, what could go wrong? If anything did go wrong, the cover up was superb.

Now to the content of the course- great refresher and some excellent new information was shared. For those of you not attending the course or those at the course who experienced post-prandial coma and missed some points- here are a few highlights from a couple of today’s lectures:

v Pathophysiology of Pain (Eduardo Bruera)-

  • Have a clear understanding of incidental pain and how this is different from treatment of break through pain
  • Only area of pain we can measure is “Expression” which has five components: cognitive status, mood, beliefs, cultural, biography
  • Have an idea of inhibitory modulators of nociception and excitatory modulation of nociception

v Pain Assessment and Barriers (Michael Preodor)-

  • Understand the barriers at the Provider, patient/family, system levels
  • Understand difference between addiction, dependence, pharmacologic tolerance, pseudo-addiction and diversion

v Principles of Pain Management (Eduardo Bruera)

  • Pain is multidimensional- if pain is increasing, one must do a complete assessment
  • Risk factors for developing Opioid Induced Neurotoxicity (OIN)include
    • High opioid dose
    • Prolonged opioid exposure
    • Pre-existing delirium
    • Dehydration
    • Renal failure
    • Presence of other psychoactive drugs
  • Diagnosis of OIN
    • Cognitive failure
    • Severe sedation
    • Hallucinosis/ delirium
    • Myoclonus/grand mal seizures
    • Hyperalgesia/ allodynia

v Pediatric Sessions (Jeanne Lewandowski)

  • Start low, titrate quickly
  • Half of all pediatric deaths occur in the first year of life, of which half are in the first month
  • Unable to declare a child dead by neurologic criteria (brain dead) in the first week of life
  • Participation of the ill child in decision making is ideal- term used in “assent”

Articles some of the speakers suggested we read:

  1. Zisook, S, Shear K. Grief and bereavement: what psychiatrists need to know; Work Psychiatry 2009 June; 8(2):67-74
  2. Himelstein, BP: Palliatve Care for infants, children, adolescents, and their families. J Pall Med 9(1) 2006, 163-181
  3. Lo B, Ruston D, Kates LW et al. Discussing Religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 2002; 287(6)749-754
  4. Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306:639-45
  5. Smith HS. Opioid Metabolism; Mayo Clin Proc 2009; 84(7):613-24
  6. Hanks, G et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. Journal of Clinical Oncology 19(9); 2542-54, 2001, May

So, we are off to a great start! Let’s see what tomorrow brings….

Tanya Stewart MD FAAHPM

Inside the Process of Authoring a Book: Diane Meier on Palliative Care: Transforming the Care of Serious Illness

Our recent book, Palliative Care: Transforming the Care of Serious Illness (Jossey-Bass, San Francisco 2010), has been a long time coming. I got the invitation from my co-editors Stephen Isaacs and Bob Hughes of the Robert Wood Johnson Foundation over three years ago. The book was to be another in an annual series of books on health reform in areas of significant investment by the Foundation. Prior volumes addressed the Campaign for Tobacco Free Kids and School-Based Clinics, among others. I was asked to both write an introductory essay placing the field in context, and to help select a series of previously published articles for reprinting in the volume. The audience for the book was a matter of some discussion- we settled on the educated public and, we hoped, health care policy makers. The reprints were to serve as the signal and seminal pieces that exemplified the evolution of the field from its inception to its current status.

Sounded simple enough.

Many, many, hours and three years later, we had a draft ready to go press. The articles were chosen with a great deal of input from colleagues in the U.S. and around the world and lots of great pieces of writing had to be left out for lack of space. My essay started with the roadside hospices for the Crusaders of medieval times and ended before the passage of the 2010 Accountable Care Act and I learned way more than I anticipated about the threads that contributed to our field now- the 14th century origins in church-sponsored hospitals for the poor and hopelessly ill; the evolution of the place of death from a familiar experience to a mistake in the “medical model” of the modern world; the new science of pain and pain management in the 1970’s; the revolutionary and determined roles of three middle aged women (British nurse, social worker and physician Cicely Saunders, Dean of Yale University School of Nursing, and University of Chicago physician Elisabeth Kubler Ross) in a male dominated medical business culture; and the power of a federal payment mechanism (the Medicare Hospice Benefit) as a mediator of social change. The development of the field of palliative care as an approach to the human experience of illness and disability stands on the shoulders of at least a thousand years of social evolution. Humbling. It helps to understand what came before in order to think about what should happen next. Some people want to use the book in colleges and universities and Schools of Public Health. Hope for the future.

ReachMD Partnership Sounds Like a Success

Have you heard yet that AAHPM has partnered with ReachMD, an innovative communications company, providing thought-provoking medical news and information to healthcare practitioners? More importantly, have you listened?

Established to help increasingly time-constrained medical providers stay abreast of new research, treatment protocols and continuing education requirements, ReachMD delivers innovative and informative radio programming via XM Satellite Radio Channel 160 and online streaming developed by doctors for doctors.

The Perspectives in Palliative Medicine series has been a huge success. With over 650 people downloading shows and others listening at home or in their cars, so many are tuning in to hear about key issues in palliative care. The latest programs,, hosted by AAHPM Executive Vice President Porter Storey, MD, include :

The Challenges to Pain Management in Geriatric Patients – 04/12/2010, with R. Sean Morrison, MD
Religious Issues Affecting End of Life Care – 04/05/2010, with Richard Payne, MD
Palliative Care’s Role in Treatment of the Seriously Ill - 03/29/2010 with Russell K. Portenoy, MD
Warning Shot: How to Deliver Difficult News – 03/22/2010, with Gail Austin Cooney, MD.
We are proud of our members who have done such a wonderful job representing the profession. If you haven’t listened yet, check it out, if you have, share your thoughts with us!

Jen Fuhrman
e-Marketing Manager

AAHPM