Archive for December, 2012

Quality Matters: A View from the Seat at the Table

On November 29, the American Society of Clinical Oncology (ASCO) hosted a first-ever Quality Measures Summit to identify a set of cross-cutting quality measures applicable to all patients with cancer, irrespective of diagnosis or place along the disease trajectory. This meeting was in conjunction with the inaugural ASCO Quality Symposium, an educational and scientific meeting of over 600 oncology professionals in San Diego focused on quality, information technology, and health services research. The Academy was kindly asked to join the Summit by members of the Quality Care Committee of ASCO, and three members of the AAHPM Quality Task Force attended this meeting to represent the views of our membership and our discipline. On behalf of Dale Lupu and Kathi Bickel, I am presenting a brief update on the proceedings of this meeting and how Academy members can lend further voice to how cancer care quality will be assessed.

In parallel to national efforts to develop quality measures that are reflective of movements towards value-based care and avoidance of low-value services, AAHPM joined the American Society of Radiation Oncology (ASTRO), National Coalition for Cancer Survivorship, Oncology Nursing Society, Society of Surgical Oncology (SOS), California Healthcare Foundation, American Urological Association, American College of Surgeons Commission on Cancer, M.D. Anderson Cancer Center, and the Livestrong Foundation to propose a set of cross-cutting quality measures that evaluate quality from time of cancer diagnosis through end-of-life care and bereavement. Prior to the meeting, we were all asked to submit potential measure concepts. Using the framework of the National Quality Forum and Preferred Practices for Palliative Care from the National Consensus Panel, we advocated intensely for: the incorporation of systematic, comprehensive symptom assessment on every visit (and that goes beyond treatment-related side effects); access to consultative palliative care; caregiver support and assessment of satisfaction with care; timely discussion of hospice; assessment and management of psychological and social needs; information sharing and understanding, including that of prognosis; and patient and caregiver understanding of intent of cancer-directed therapies. These were presented with corresponding quality measure examples and supported by publications from palliative care literature.

In what still remains with me and my colleagues as the lasting impression of this meeting, is the acceptance of, at face-value and with minimal discussion, most of the palliative care quality measure concepts presented at the Summit. With the exception of a concept involving systematic assessment of symptoms, where an intense discussion ensued regarding the scope (i.e. which symptoms to address), frequency (i.e. which visits should assessments occur on), and methods (i.e. what tool to use, should we advocate for a specific tool) of a potential measure; concepts and principles addressing palliative and end-of-life care seemed as germane to the understanding of how high-quality cancer care should be delivered as radiologic imaging for staging of new disease. Moreover, once-foreign concepts such as attention to advance care planning and regular involvement of palliative care teams have become accepted components of cancer care delivery worthy of measurement, reporting, and improvement. Although domains such as assessment of caregiver satisfaction and psychosocial distress spurred lively discussion regarding details of the structures and specific tasks these would entail, it was clearly accepted that these areas are within the scope of practice of oncology care. Furthermore, we agreed with the other participants that logistics and details are important areas of discussion; even as a discipline, we are maturing our own processes to meet these areas of quality within secondary palliative care.

Currently, these proposed measures and concepts are now being distributed among workgroups to further hash out details of wording, scope, and essentials of measurement. These include defining populations and settings to which the measures would apply and describing steps for feasibility testing of the potential measures in real-life settings. As this moves forward, members of the Academy’s Quality Task Force will remain integral players in the world’s largest oncology membership organization initiative to develop cross-cutting quality measures. This initiative is also in-line with several efforts that involve the Academy and its members in working with ASCO in further integrating palliative care education into the continuing education of oncology professionals and the curriculum of oncology fellows. All of these efforts have strengthened the relationships between both AAHPM and ASCO, on the staff, investigator, and leadership levels. And this has created further avenues for cooperation on efforts that improve the care of all patients with cancer.

A common theme heard from speakers and attendees of the ASCO Quality Symposium was one that originates from the writings of Brent James, a noted policy expert on quality from Intermountain Healthcare. Colloquially, it goes something like this: “Quality is about enhancing reliability of delivery – you don’t have to get it right, just get it consistent first. Then, perfect the consistent care until it’s right.” In many ways, since the publications of the article by Jennifer Temel and the subsequent Provisional Clinical Opinion by Smith et al., we are transitioning from demonstrating the proof-of-principle that palliative care is valuable and needed in cancer. And now, we are evolving from proving our value, to – literally – having a seat at the table during important conversations of what ideal cancer care should look like. This involves ensuring that the spirit, principles, and expertise of palliative care are consistently and reliably interwoven into the tapestry of oncology care.

Since my youth, I’ve been taught that consistency builds trust. And ultimately, it is this trust that quality of life will be valued, improved, and preserved that our patients place in all of us. And it is nothing short of remarkable that, we are – in collaboration with our partnering professional organizations – getting closer to that ideal.

Arif Kamal, M.D.
AAHPM Quality and Standards Task Force
Director of Quality and Outcomes,
Duke Cancer Institute
Director, Palliative Care and Quality Research
Center for Learning Health Care, Duke Clinical Research Institute

Too Few Gray Hairs?

“You have a lot to learn,” he said sternly as the heat in his voice rose and his finger stood tremulously in front of my nose. “How old are you? I demand to know.”

This is what my home visit to an 82 year old hospice patient devolved to as I told him that he should no longer be driving. I reminded him of the several falls he had taken recently in parking lots and in stores. I reminded him of his recent fender bender. “Trust me,” I said. “If I had a 30 year old patient with your disease and medication profile, I’d say the same thing.”

”I don’t trust you. Now get out!”

I’m a 32 year old woman awaiting board certification in hospice and palliative medicine. I’m fellowship trained in the fields of hospice and palliative medicine, and at this point in time, I’ve spent most of my life in school or in training for this, my dream job. This is my first year as an attending physician. I spend my day visiting hospice patients in their homes; some are imminently dying, requiring family conferences on the fly to glean understanding from family members and to ensure my patients are getting maximal symptom management. Some of my patients are really of the palliative care sort, either referred to hospice too soon or not fully in line with the hospice mindset. These patients are just as challenging. My patients and their families generally share with me everything about their lives, past and present, as I’ve found that the concept of dying often allows people to open up about things they never dreamed they would. They tell me of failed relationships, beautiful family memories, run-ins with the law, things they regret, and things they are most proud of. What my patients and families generally don’t tell me is whether or not they trust me, the young-looking woman who is in charge of theirs or their loved one’s final phase.

I do often hear age-related comments about my appearance. The most popular of these (“You don’t look old enough to be a doctor!” and “Are you Doogie Howser?”) are often inserted in the middle of an in-depth and sensitive conversation about death and dying. It’s what is unsaid that makes me nervous.

Do families discount what I spent hours saying because of my appearance? My age? My relative lack of life experience? Do they dismiss whatever I may say over the ensuing two hours when they see “the very young doctor” walking through their door? When I touch on sensitive topics, like driving, are patients and families less inclined to hear my concerns for all who are on the road because of my age and inexperience as a physician?

Of course, all physicians must start out in their first attending job. In primary care, however, my job as a physician is based mostly on guidelines, with a good amount of evidentiary support for run-of-the-mill problems. I don’t need a lot of life experience to discuss these issues with patients and patients understand this. In palliative care, where issues are neither black nor white, it helps to back up recommendations with experience in medicine and in life.

As hospice and palliative medicine emerges as a critical medical specialty, and as fellowship training is (as of 2013) the only way to obtain certification in HPM, our physicians will be entering the field at a younger age and with less experience. Will this be a detriment to our field? To this point, a lot of our physicians have come to palliative care as a second or third career in medicine, lending their expertise in areas like neurology, emergency medicine, geriatrics, and surgery to patients at the end-of-life, and advancing our specialty in credibility and trustworthiness. Will this change with the new breed of 30 year olds responsible for continuing the charge?

I do have a lot to learn. I agree with my very angry patient. But I know a lot, and I know a lot about the good death and about symptom management leading up to the good death. I feel that I am a skilled communicator, thanks to my training, and good at building rapport quickly. I also have a lot to say, and a lot to bring to my chosen field. Considering and appreciating all of the things I can do, what I can’t do is change time. So from here, I’ll look forward to living more life and learning more every day.

Maybe from now on, I’ll find myself asking my hairstylist to leave the gray strands in.

Bethany Calkins, MD