Archive for July, 2013

The Learning Curve of Fellowship

Conrad Williams IV, MD

Conrad Williams IV, MD, serves as fellow section editor on the Quarterly Editorial Board. In the Q&A below, Williams reflects on the path that led him to hospice and palliative medicine and what, as a fellow, he can expect for his future.

What compelled you to choose to specialize in this field, which is intrinsically emotionally draining?

Entering residency, I had no idea of what palliative care encompassed; to me, it was hospice care. As I learned more about the field, I quickly realized I had found my calling. In medical school, we are presented with and tested on all sorts of diseases and innumerable ways to treat the problems. In residency, however, you suddenly realize there is much more than a disease involved. Patients are not defined by their illnesses, and, especially in pediatrics, there are families that must be cared for as well. Many people choose pediatrics because kids “get better.” While this is certainly true in many cases, I quickly realized that some kids do not get better, and we often fail patients who need us most—those with chronic, life-limiting conditions. Medical school does not prepare us for that transition—we need a disease and an intervention. It is easy to talk about “the hypoplast status post Norwood,” that “CF’er who is back again because he just won’t do his daily home treatments,” or, even worse, “Bed 12.” As hospice and palliative medicine physicians, we are allowed an intimate relationship with patients and families at a time of intense vulnerability. We accompany our patients on the part of their journey that requires the most help; yet, it is the part that many providers distance themselves from because they are not prepared to care for this population.

What also excites me about the field is the potential. The trailblazers in pediatric palliative care are in the prime of their careers, affording those interested in the field an opportunity to learn alongside teams that helped define the specialty. What started as an art is gaining more and more of a scientific identity as the evidence supporting the specialty’s importance in our healthcare system quickly grows. The chance to play a role in creating an identity for what is quickly becoming a more established specialty is exciting.

Was the learning curve initially steep?

A challenge I was not expecting was the difficulty with transitioning from residency right into my fellowship. As residents, we are very task- and checklist-oriented. We get in early for rounds, focus on how to fix our patients’ diseases, and leave all the other “stuff” to social workers, case managers, bedside nurses, child life specialists, and others. Now I cannot do my rounds when our patients and families are sleeping, I cannot do an effective job without sitting down and giving them my time. I have had to make a conscious effort to be more mindful and present during my encounters. As I transition from resident to fellow, I have found it challenging to keep my mind clear and stay present during my visits with patients.

What have been some of the ups and downs?

If I could only do home visits for the rest of my career, I would be happy. To be welcomed into such a private space is an honor and allows me to get to know my patients on a new level. It places me in an comfortable environment, both physically and emotionally. Most families truly value time spent with their providers outside of the hospital.

The biggest “down” has been the geographic separation from my wife. In such an intense and emotional job, I need someone to debrief and relax with. Because my wife is also a pediatrician in fellowship and there were few options for where I could train, we are spending this year apart. Suffice to say, I am not a “phone person.” I have had to rely on coworkers and my chocolate lab, Nola.

What challenges do you anticipate as your career begins?

Fellows often find themselves entering jobs with leadership positions beyond their skills as junior faculty. Halfway through my fellowship, I have begun my job search in earnest with feelings of great anticipation accompanied by the unsettling sensation of my stomach creeping into my throat. In 6 short months, I will be faced with more than just a job as a clinician. Not only will I be developing my style as a hospice and palliative medicine physician, but I will also be labeled with titles such as team leader, administrator, educator, researcher, conflict resolver, and business planner. I will enter a whirlwind of institutional culture and politics, and I will need to remember the rules of sandbox etiquette, all while contributing to the development of a crucial and effective system of delivering high-quality palliative care to children and their families. I have begun to develop my leadership skills and create a network of mentors that can be a resource as I grow into my career.

Conrad Williams IV, MD, is a fellow section editor on the Quarterly Editorial Board. He is currently a fellow with Haslinger Family Pediatric Palliative Care Team at Akron Children’s Hospital, Akron, OH. Contact him at cwilliams3@chmca.org.

The Pros and Cons of a Fellow Match

Nicky Quinlan, MBBChBAO MRCPI, and Conrad Williams IV, MD

Hospice and palliative medicine (HPM) is growing as an accredited specialty, in keeping with the growing need for timely palliative care for the seriously ill population of all ages. Currently, the only route to HPM board certification is through an accredited fellowship. HPM has not yet joined the National Resident Matching Program (NRMP) match process, whereas geriatric medicine will have its inaugural match day in January 2014. We believe it is time for HPM to participate in what has become the gold standard process for fellowship fulfillment. We elicited opinions of and experiences with the current asynchronous “nonmatch” application process from colleagues to assess the pros and cons.

Challenges of Rolling Admission
“My top three programs had interview dates separated by 4 months each, leading to my having missed the deadline for one, being offered a position by one, and then not being able to interview at the third because of the length of time prior to their selection process,” one colleague reported. “In my opinion, we have ‘arrived’ as a subspecialty and we need to act like it, including joining, at a minimum, the timeline of the NRMP. This makes further sense due to the number of programs that are transitioning to using the Electronic Residency Application Service as an application tool.”

Another physician commented on how the rolling fellowship admission process affected her family. “Without a formal match, I watched my husband be forced to make huge career decisions on the information he had at that moment rather than all of the information that could be available. Getting fellowship offers at different times forces people, and families, to act on urges rather than thoughtful, prediscussed plans. When more than one offer comes into play, it turns medicine into a business, and in essence, is no longer a true match. I also find it ironic that my husband and I could couples match in residency and happily live together for 3 years, but when it came to applying for fellowship, this was not a possibility. If palliative medicine became a formal match, it would allow for the possibility of some couples matches if the timelines were the same.”

One of our respondents also suggested how the match program may help the field better compete with other specialties. “I emailed the program director directly and interviewed informally at a medical conference and then later formally with program faculty. Shortly thereafter, I received an offer that overlapped with an offer from a different program at the same institution. It was a tense time to decide which specialty to pursue, but it has worked out well for me. I can see how the match can level the playing field for all involved.”

A Case for Rolling Admission
One physician who benefited from the rolling admission process remarked, “My process worked out well for me because I came to palliative care after all of my fellow classmates went through the match. Palliative care as a service came late to my hospital (during my second resident year) so it was [my] third year by the time I was fully exposed to it and knew I wanted to pursue it as a career. That meant I would have had to wait another year and perhaps [the program] would have been with one less fellow. The nonmatch rolling admission process was a win-win for both me and the program.”

We have reported the experiences of only four fellow candidates, and this by no means represents the entire applicant population. However, we have tried to provide a sample of varying experiences and opinions. Given overlapping and disparate rolling admissions for various programs, it appears many candidates are afraid of shooting themselves in the foot or, worse yet, burning bridges with programs by accepting a position then later rescinding it. The uncertainty and apparent stress inherent in the current application process is palpable in the responses.

AAHPM has met with representatives from NRMP and has made available an informative webinar on the match process targeted to program directors (www.aahpm.org/resources/default/national-resident-matchingprogram-webinar.html). Interest surveys have also been distributed and collected from hospice and palliative medicine fellowship programs.

The AAHPM Board of Directors will consider a recommendation by the Leadership & Workforce Strategic Coordinating Committee and Academic Palliative Medicine Task Force to move forward with the next steps necessary toward Academy involvement in the NRMP match over the next several months. What are your thoughts and opinions?

Collaboration Between Palliative Medicine and Oncology

Larry Beresford

The opportunities—and the imperatives—for the palliative care field to collaborate with other physicians, and with oncologists in particular, are detailed in an article I wrote for the latest issue of AAHPM’s Quarterly newsletter. The Academy is partnering with oncology groups on a number of fronts, including a joint project with the American Society of Clinical Oncology to test technological approaches for getting the latest palliative care research into the hands of working oncologists. The Academy was also represented at a recent meeting hosted by the American Cancer Society’s Cancer Action Network to talk about how to advocate for palliative care in Washington. This kind of collaboration increasingly points toward the largely uncharted realm of out-patient and community-based palliative care where many of the patients we want to reach receive their care from oncologists and other physicians.

As this article was being finalized, a similar exploration of the palliative-oncology interface was offered in a June audio-conference from the Center to Advance Palliative Care on “embedding palliative care in the oncology clinic” by palliative care leaders from Massachusetts General Hospital. These examples reflect the growing consensus that there simply won’t be enough trained, board-certified palliative care specialists to go around in a rapidly reforming healthcare system that is finally starting to recognize their intrinsic value for patients with serious illness.

Given current and anticipated hospice and palliative medicine workforce shortages, there needs to be some way to leverage this precious resource for maximum impact. And that would seem to demand better integration with other providers through a kind of two-tiered system of palliative care. Primary care physicians, oncologists, and other specialists would be oriented to the basics of providing palliative care for their patients, while cued to when a more specialized approach is needed via referral of their more difficult cases to palliative care specialists.

Oncology is a logical place to start experimenting with this approach, as the quarterly article describes. We’d love to hear how your palliative care program is pursuing greater integration with oncologists and other specialists and involving them in providing primary-level palliative care. Perhaps the next great arena for collaboration, coordination and integration is with the more than 30,000 hospitalists now practicing in U.S. hospitals. They, too, are centrally located to identify patients who need palliative care and to provide the palliative care basics for the majority of such patients.

Moving PCHETA on Capitol Hill: A Q&A with the Academy’s Lobbyist

Years of Academy effort to develop legislation that expands opportunities for interdisciplinary education and training in palliative care paid off last summer when the Palliative Care and Hospice Education and Training Act (PCHETA) was introduced in Congress by Sen. Ron Wyden (D-OR) and Rep. Eliot Engel (D-NY-16). (Access a summary of the bill.) In March 2013, Sen. Wyden and Rep. Engel – PCHETA’s congressional champions – were joined by Rep. Tom Reed (R-NY-23) and additional cosponsors in reintroducing the bill (H.R.1339/S.641) in the new Congress, and they need stakeholders to help move PCHETA forward on Capitol Hill.

AAHPM Public Policy Committee Chair Stephen A. Leedy, MD FAAHPM, spoke with Sue Ramthun, a principal and senior vice president with Hart Health Strategies, AAHPM’s DC-based lobbying and consulting firm, about the bill’s chances in Congress and how individuals can help grow support for the measure. (Read more in the Summer 2013 issue of AAHPM Quarterly.)

Now that the bill has been reintroduced, what are the prospects for it passing?
An Act of Congress is no easy task. It takes a lot of education and attention to compete with the thousands of bills introduced each Congress. In the last Congress (2011–2012), 10,444 bills were introduced in the House and Senate, while 283 new laws were enacted (2.7% of the total). However, the statistics are deceiving, because legislation rarely passes on its own. Rather, bills are packaged together in a broader theme. Either way, it is important to build momentum and keep your eye on the goal. The introduced legislation is your vehicle for educating members of Congress about you, your patients, and palliative care workforce needs. Seeking support for PCHETA builds visible support so, when the opportunity presents itself, there are Members of Congress to push it over the finish line and know that people back home are watching.

What does it mean that the bill includes an “authorization” for appropriations ($49.1 million/year for 5 years)?
An authorization is the legislative term for giving permission in the law for a federal agency to spend money. Authorizations typically outline the amount of money that can be spent, for what purpose, and who may receive the money. In this case, up to $49.1 million in 1 year. The actual funding is determined through the annual appropriations process. There is no guarantee that a program is fully funded up to its authorized level. The appropriations committees may take into consideration whether a program is unauthorized, meaning it was never authorized or that its authorizing authority has expired. Entitlement programs, like Medicare and Medicaid, are treated differently since they are considered mandatory spending. However, discretionary health programs (e.g., National Institutes of Health, Centers for Disease Control, and public health programs) are subject to the authorization and annual appropriations process.

Some members of Congress say they won’t support a bill that adds to the federal budget. How do we address these concerns?
Congress is living under different budget rules than in the past. Currently, federal programs are subject to across-the-board cuts (sequester) to bring spending to the previous year’s level. Members of Congress are asked to support a plethora of worthy programs important to their constituents. Congress is required to offset increased spending with comparable reductions in other programs to pass a bill. Therefore, some Members are reluctant to support legislation that does not identify spending cuts in other programs. On the other hand, it’s difficult to find an offset that is easily supported by all. Therefore, it is imperative to educate, educate, educate—and support your arguments with data. A clear need must be articulated to change policy, with data to document the workforce shortage and resulting effect on patient access. That message is stronger coming from constituents so Members of Congress know of interest back home.

What can individual AAHPM members do to help advance this legislation?
Advocating for PCHETA is a shared responsibility. You can help by sharing your experience and stories. You are the constituent, the patient advocate, and the expert. Your Representative and Senators need to hear from you. The time you take from a busy practice is appreciated and makes a statement. Although it is nice to meet with your Representative and Senators in Washington, DC, there are many other opportunities to speak up without leaving your home or office. You can call and leave a message for the Member or ask to speak to their health legislative assistant. You can e-mail (regular mail is not as timely) via the AAHPM Legislative Action Center. Members of Congress work in their district or state office about 1 week each month and are there many weekends. You can request time to meet with them during the District Work Periods or attend a Town Hall meeting or other event in which your Member participates. Check out their websites and sign up for their e-mail updates to learn of local events and opportunities. You can also invite your Members of Congress to visit your practice. This is a very effective way to directly show them what you do and the effect on patient care. As physicians and other providers on the front lines of patient care, your direct communication and outreach to congressional offices helps them to better understand palliative and hospice care and the need to ensure an adequate workforce to meet current and projected needs. Developing these personal relationships with Members of Congress and their staff takes time, but results in a much better understanding of palliative care and its importance in the continuum of care.

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Access the Academy’s Legislative Action Center, and contact your representatives to ask that they sign on as supporters of PCHETA. Send an e-mail that combines your personal experience with hospice and palliative care and a few of the suggested talking points AAHPM has provided. If your members were cosponsors last Congress but have not yet signed on, you can send them a message expressing your gratitude and your hope that they will again support the bill now that it has been reintroduced. (Find out if your senators were past cosponsors here, and find out if your representative was a cosponsor here.) Share this link with any of your colleagues, and ask that they too weigh in with their members of Congress – you don’t have to be an AAHPM member to use the Academy’s Legislative Action Center.

Education Resource Email #4: PalliTalk

Dear Education SIG members,

Welcome to the first new Education SIG Resource Email of the year. This email provides further information on “PalliTalk” which you heard about in an email on this listserve last week.

PalliTalk is a train-the-trainer course for palliative care faculty interested in learning to teach communication skills to their fellows using simulated patients. The course will be held in Aspen, Colorado at the Aspen Meadows. The dates for the course are: September 30-October 3, 2013. The course is partially funded by a donor who wants to ensure that every HPM fellow receives intensive communication skills training during their fellowship.

The course has been created by Tony Back, Bob Arnold, James Tulsky and Kelly Edwards. This team, along with Walter Baile, developed Oncotalk back in 2002. For those unfamiliar with the program, Oncotalk was a communication skills training retreat for oncology fellows that showed impressive results in terms of how it was able to change behaviors (Back AL et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007; 167:453-460). This program ran from April 2002- October 2004. The same team followed this program with Oncotalk Teach, a train-the-trainer course for oncologists that focused on teaching oncologists how to teach their fellows about communication during real patient encounters. Several other courses created either by this same group or by the junior faculty involved in these original projects are now up and running including: Intensive Talk, GeriTalk, WeTalk, and Nephro Talk. Now, after all of this work focused on other fields, Palliative Care finally gets its own national faculty development program with PalliTalk.

As mentioned in the email from earlier this week, I am one of the faculty for PalliTalk. Besides giving further information about the program and its history, I thought it may be helpful to use this email to share my experience with these programs. When I was a fellow, I attended the original Oncotalk as a learner. My program director encouraged me to go and, while I loved the idea of an all-expenses paid trip to Aspen, the idea of doing role-play for a week was less attractive. I had always hated role play and did not find it helpful. What I experienced at Oncotalk, however, was a completely different role play experience. It felt safe and it was focused on what I wanted to learn. I could see myself gaining skills as I tried new things. And, unbelievably, it actually became fun! This was a transformative experience and I have since focused my career on this type of teaching, working on several of the courses mentioned above, including Oncotalk Teach and WeTalk. I find it so rewarding as a teacher because every session is different and challenging and you get to watch your group grow, learn and change before your eyes.

What you can expect at PalliTalk is an introduction to this model of teaching communication skills. The majority of the time will be spent in small groups practicing your own teaching. You will essentially be role playing how to run a role play. You will identify your learning goal as a teacher, you will then try running a role play and will time out when you get stuck. You will identify where you were stuck and will brainstorm with your group and then you will get the opportunity to try a new approach and see how it works differently. As we’ve seen in other similar programs, we expect that, by the end of the week, you will feel empowered by the new teaching skills you have worked hard to gain.

If you missed the email from earlier this week, here is the information again:

PALLITALK

A unique train-the-trainer conference that will equip Palliative Care faculty physicians to run small group communication skills training workshops for their fellows. Using evidence-based methods based on expertise acquisition, you will experience the learning model we developed in Oncotalk, then learn the small group facilitation techniques we use. We’re aiming this course for physicians who could run a short workshop for their Palliative Care fellowship program. We encourage 2-person teams because the f2f co-mentorship accelerates your development.

4 days of learning and networking in beautiful Aspen -Monday, September 30, 2013 at 8:00 AM – Thursday, October 3, 2013 at 5:00 PM (MDT)

The faculty will include Anthony Back, Bob Arnold, James Tulsky, and Kelly Edwards, who have been working together for over a decade. Other faculty include Gordon Wood and Holly Yang (watch our blog for updates at vitaltalk.blogspot.com).

Details: The tuition for the course is due 30 days prior to the course and will be $1000 for the four-day course. This includes lodging, breakfast, lunch and two dinners. This course is being supported by a donor. In the next iteration, the cost will be much closer to the market value of the course. The $100 ticket fee holds your spot and is nonrefundable. We’re limiting the course to 24 participants, so apply now!

APPLY TODAY at http://vitaltalk.eventbrite.com

Please feel free to contact me or any of the other faculty with questions.

Gordon

Gordon J. Wood, MD, MSCI, FAAHPM
AAHPM Education SIG Chair-Elect