Archive for February, 2013

Shaping the Future Campaign – A Member-Driven Campaign

I regard the Academy as my “professional home.” As a longtime AAHPM member, I’ve seen the Academy shape, enhance, and advance the field of hospice and palliative care and fully support its membership. The Shaping the Future campaign is no different; the funds raised will go toward programs that members themselves have requested, be it advocacy, workforce development, or education—or all three areas.

The campaign is a way to enhance the reach and depth of what the Academy can do, and be responsive to what members say is important to them and the field. Members tell us that there still a lot to be done in terms of advocacy to ensure that everybody who has a serious illness has access to high-quality palliative care. The ways to do that are to have more well-trained palliative care providers, be accessible and available to people who need care, have the reimbursement mechanisms to make it fiscally viable, and have the evidence to inform practice.

I urge all members to become actively engaged in the campaign. Every gift will make a difference.

Visit aahpm.org and click “Donate Now” on the lower left corner of the home page to make your donation today.

Jean Kutner, MD MSPH FAAHPM, of the University of Colorado School of Medicine, Aurora, CO, is a current member of the AAHPM Board of Directors and Executive Committee, and will be President-Elect following the 2013 Annual Assembly.

Choosing Wisely in Hospice and Palliative Medicine

Has this happened to you? Your elderly patient can’t sleep their last night in the hospital before being discharged home with hospice care so the on-call physician orders a sedative-hypnotic. When the patient becomes confused and agitated, a CT scan of the head is ordered. Or how about this one: Your patient with stage IV non-small cell lung cancer is referred for screening colonoscopy. I’m sure you have your own stories. Experts estimate that one third of US healthcare spending, over $700 billion annually, is for care that is non-beneficial or even harmful.

Seeing treatments and tests reflexively ordered when the potential for benefit is low or the risk of harm is high, particularly for the elderly and people living with serious illness, was a major source of distress to me as a resident. That distress, and a belief that evidence-based medicine could guide us to care that is more effective, accessible, compassionate, and sustainable, lead me to a career in palliative medicine. It is precisely this hope that underlies the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign.

The goal of Choosing Wisely is to challenge medical specialties to come up with their “top five” list of treatments, tests, or procedures that should be questioned because best evidence shows they are non-beneficial or even harmful. As a recovering molecular biologist, I confess, I devoutly believe that science that informs our compassionate care is the best way forward. All this is by way of explanation for the madness that overtook me when I agreed to serve as Chair of the AAHPM Choosing Wisely Task Force.

The challenge was significant. We had a relatively short timeline to build expert consensus on our list of “Five Things Physicians and Patients Should Question” in Hospice and Palliative Medicine. Striving for an inclusive and transparent process, we also wished to incorporate member feedback into the list development process. Fortunately, I was blessed with a wonderfully talented group of Task Force members.

To start the process we elicited suggestions for the list from the AAHPM SIGs as well as Task Force members. We used these to develop a short list of recommendations and then sought feedback from Academy members. We received close to 700 comments from more than 300 members ―vital input that informed the Task Force’s final selection of AAHPM’s recommendations and drafting of the precise supporting language for each item on the list. Finally, last Thursday, our recommendations were revealed – along with those of sixteen other medical specialties – during a press event in Washington, DC. (Visit choosingwisely.org to access the complete lists from all participating specialty societies and watch a video of the Feb. 21 announcement and panel discussion.) Each society, traditional and social media, along with Consumer Reports, Wikipedia, AARP, NHPCO and other consumer advocates are all contributing to the broad dissemination of the campaign.

With the final list announced, the real work now begins: supporting critical conversations between physicians and their patients as they collaborate to ensure the best care possible. To support those conversations, AAHPM has developed a set of talking points for members (login to Members Only required). Our AAHPM Choosing Wisely Task Force has also written a Special Article describing our “Five Things” in greater detail. Look for it in the March issue of The Journal of Pain & Symptom Management.

I’d also like to invite you to attend the Advocacy Forum at the AAHPM & HPNA Annual Assembly in New Orleans next month where my fellow Task Force members and I will discuss our Choosing Wisely recommendations and how you might choose to discuss them with your patients and the public. (Learn more.)

I’d love to hear your thoughts about AAHPM’s Choosing Wisely recommendations. What do you think of the list? Will you use it in the care of your patients? If so, how? What other recommendations would you like to see on any future lists?

Whether or not your “Five Things” list would be identical to AAHPM’s final version, I hope you find it a useful tool to engage patients, families, and the public in choosing wisely.

Daniel Fischberg, MD, PhD
Medical Director, Pain & Palliative Care Department, The Queen’s Medical Center
Chief, Division of Palliative Medicine, and Professor, Department of Geriatric Medicine, John A. Burns School of Medicine of the University of Hawaii
Honolulu, HI

The Feel-Good File

In my very first week as a home hospice physician, my mentor, a veteran home hospice doctor told me, “Start a feel-good file. It’s important.” I nodded in agreement, mentally documenting new EHR passwords and the location of the bathroom.

I think about the words “feel-good file” often. Honestly, I once found it to be a pompous thought; if I was hearing her correctly, my instruction was to gather kind words about myself for my own good. I wasn’t sure how I could be more important than those I survive, or the family that I am apart of. Eventually though, cards and small gifts started floating around my computer bag and my home, leading me to stuff these mementos in a drawer in my bedside table. There I had it, my makeshift “feel-good file”. Good for me. I followed directions.

Good for me indeed. These words were all either sent to me or given to me by patients and their families, thanking me for my services as their hospice doctor. What a special thing. I found myself wondering if any of my friends or family had a “feel-good file”. It wasn’t likely. As professionals in hospice and palliative medicine, we are so very lucky.

It used to be that when I received a card or gift, I’d show my husband what was written about me and beam. In my eyes, those words were written by people in the worst time of their lives. What an honor that they would take the time to write me about their experience when there were certainly more pressing demands on their time. In some ways, sharing these cards was a good way to depict the intensity of my job with my non-medical husband. As I had come to discover, however, these words of warmth, appreciation, and gratitude weren’t always accepted with pride.

I very rarely have to work. Most days at my job as a hospice home-care physician are spent enjoying time with patients and families; sort of like days with old friends, sharing stories, experiences, and prayers (those on-call weekends, on the other hand…). I don’t consider it work. It’s an honor. My husband, however, has a tense job working in the stock market, with deadlines, stressful daily human interactions, and a several hour daily commute. These cards and kind words represent recognition by community members, all for doing my job. I suspect that every card, gift, and drawing that I received reminded him of a fulfillment that he didn’t have in his career.

When I sensed his discontent, I stopped showing him my cards. But I keep them close to me in my makeshift feel-good file, which has become more important to me than my mentor knows.

Let’s face it: while our job is beautiful, immensely gratifying, and glorious, our job is also taxing, nerve-racking, and sad. We meet new people all of the time, get to know them, get to love them (or like them in the case of some COPDers), and we lose them. We go to funerals, memorial services, and services of remembrance. I often struggle with wanting to keep contact with families after their love ones’ death, but am cautioned by many to keep some distance. Such close, intense relationships built in a short amount of time, only to have them dissolve in an instant. It doesn’t quite seem fair to any of us. My “feel-good file” reminds me of journeys I have walked with patients and families, of the weather on the day I first met them, where I was when I heard of their death, and first impressions that may or may not proved true. Review of the “feel-good file” reminds me of snap decisions that I made in the time of crisis, and the joys of an intractable symptom, managed. It reminds me of where I started as an attending and how I’ve grown. It reminds me of how lucky I am to be able to do this job and meet wonderful families in my community each day. Looking ahead, I think the “feel-good file” will help preserve myself for use by others by attenuating burnout. It will stand as a constant reminder that I’m doing good for people, and that this job, like the stock market, is full of both risk and reward.

Yet, I haven’t been able to shake the bit of guilt I feel for having a drawer full of nice things that people have written about me. I have often thought that I feel too good when I’m complimented by co-workers, patients, or their family. Additionally, I have heard co-workers comment on compliments that they have received. Are we a field that thrives on positive feedback? Or do we just need it to do what we do?

Of course, an unintended effect of the “feel-good file” is the constant worry about those whom I felt connected with but never heard from again after a loss. I know I should not expect any feedback on my position in their life, but I often wonder if I did something wrong. Did they view my services as detrimental in any way? I would argue that a drawer full of only positive feedback is dangerous without some balance. After all, there isn’t much to learn from positive feedback.

I should have asked my mentor why a “feel- good file” is so important. I suspect she would say something to the effect of, “Because life is hard” or “It’s good to be appreciated.” Ours is a difficult job, undoubtedly. Ours is a job filled with perpetual loss where we are giving our inner-most self to strangers. Our rewards, however, are plentiful, and sometimes they begin with “Dear Dr. Calkins…”

Bethany Calkins, MD

A Paradigm Shift in Medicine

Since 2010, I have been actively engaged The Personal Caring Initiative at Mayo Clinic Health System and I have given a lot of thought to the future of caring for seriously ill people and spent many hours in front of diverse audiences talking about health care and palliative care. Most recently, I have created a model of a paradigm shift in medical care that I think exemplifies a paradigm shift in medicine to reintroduce healing to the medical mandate to provide better care for seriously ill people and those they love. Often when speaking about this I receive questions about why it is necessary to change how palliative care is funded and I have applied simple restaurant guide techniques to explain the palliative care financing problem. Perhaps this is helpful to you.

The Current Medical Model
The current model of care is one that is problem based and represented on the left side of the table below. For each diagnosis is a corresponding treatment. This has largely been the success of the last several decades of medical discovery and improved treatments. Thankfully, these discoveries have been made and have resulted in improved therapies and ultimately in increased longevity. All of these developments are wonderful, however, today people living
The Disease Treatment Model and the Lived Experience of Serious Illness

with multiple diagnosis's are at risk for a new modern medical problem. Namely, they are at risk for increasing burden of disease, burden of treatment, difficult and increasing symptoms, and declining function. Despite how we train medical professionals, the Best Care Possible, isn’t the sum total of the treatments for seriously ill people. I observe learners competing to make the longest problem lists and corresponding treatments. The same students struggle communicating with people about their hopes, fears and overall goals. How do we ensure equal attention to the biology of disease and the lived experience of the patient and family?

The Paradigm Shift
In clinical situations, where the sum total of the treatments doesn’t add up to the best care or even increased longevity, the medical mandate has to explore the right side of the table. Preferably the medical mandate would represent both sides of this table. Attention to the goals of the patient and family start to guide which therapies will contribute to the goals they have defined for themselves. Expert symptom management accompanies their goals to enhance their quality of life. The right side of the table is largely representative of palliative care. The entire table represents a concurrent approach to seriously ill people as a partnership between palliative care and other disciplines. Palliative care and the right side of the chart largely represents the long lost art of healing which took a backseat to medical discovery in the last many years however, once again healing is regaining importance as the success of medical discovery has rendered many suffering from the ill effects of co-morbid illness and strenuous treatments. Changing the way we practice and educate next generations is foundational to this paradigm shift and palliative care must lead the movement.

The Restaurant Guide to Funding Concurrent Care
Quite simply, if we had to apply dollar signs to the chart above the diagnosis column would get maybe $$$$. The treatment column would get $$$$-$$$$$$ depending on the treatment. In contrast the entire right side of the chart would get maybe a half a dollar sign, even though patients and families really value what is offered in a healing, goal based approach to care. Necessity and financing are why healing has taken a backseat to medical developments. Now we see a surge in the development of palliative care to reintroduce healing to the seriously ill and perhaps the dollar signs are going to be distributed to ensure all seriously ill patients received concurrent problem based and goals based care, with increased quality of life and increased longevity as Temel’s study showed lung cancer patients live better and longer when both sides of the table work concurrently. I am no medical economist, obviously, however it would appear that the future of palliative care funding would result in a reasonable number of dollar signs to match the value of increased quality of life and longevity in the face of increasing symptoms, declining function and knowledge of the frailty of life and possibly the approaching end of life.

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