Archive for November, 2013

Education Resource Email #6: Intensive Talk

Dear Education SIG Colleagues,

Over the years, many of you have likely become familiar with or participated in Oncotalk and similar courses (e.g. Geritalk, Critical Care Communication Course, Nephrotalk) aimed at improving communication skills of trainees. Through palliative care fellowship and early career development, I felt like I had developed the target communication skills of these courses. However, as an educator, I struggled to pass these skills on to trainees, relying mostly on modeling and discussion. I have yearned to develop a more robust repertoire for teaching communication skills.

IntensiveTalk was a program which fulfilled these faculty development goals for me. Through IntensiveTalk, I developed a deeper understanding of the use of small group teaching and simulation to teach communication skills. IntensiveTalk was led by a group of expert palliative care communication educators/investigators through VitalTalk (http://vitaltalk.blogspot.com/) who also recently directed a similar faculty development program, Pallitalk. Since there will likely be similar faculty development programs in the future, I thought it would be helpful to share some information about the IntensiveTalk Course.

The IntensiveTalk course was comprised of 2 three day retreats in Pittsburgh. Ten different institutions were represented, with each institution sending a palliative care faculty member along with a critical care faculty colleague. Before the course, I was curious about how this mix of palliative care and critical care faculty would work. How would the investigators make sure that everyone was on the same page about the target communication skill-set? Would there be noticeable differences between the two specialties which would interfere with development of the teaching skills? This concern quickly became negligible, and I think the structure of the first retreat largely played a role in this:

     1. Day 1: Through a combination of large group and small group sessions, faculty participants learned about target communication skills for giving serious news and redefining goals of care. The two small groups were each an equal blend of palliative care and critical care faculty. In the small group sessions, faculty participants took part in simulated family meetings with trained actors. These sessions served as a way to ensure that each faculty participant understood the target communication skills, gave participants an introduction to the teaching method, and also provided a sense of what it’s like for learners to take part in the teaching method (e.g. what it’s like to be in the “hot seat” talking to a simulated patient or family).

     2. Day 2: On this day, the focus pivoted towards the skills necessary for facilitating the simulations from day 1. The “learner hot seat” was now inhabited by a “simulated fellow” and the participants now took their place in the “hot seat” as a facilitator. The investigators provided a facilitation roadmap, and each participant was given opportunities to practice key steps in the roadmap (such as helping learners to set goals, how to use time-outs to effectively debrief, and eliciting take-home points from learners). To further emphasize the importance of the facilitation roadmap, the investigators continued to use this roadmap to facilitate participants as they learned the roadmap and target facilitation skills!

     3. Day 3: This day offered further opportunities to practice facilitation followed by a session for each institutional dyad to consider their plans for developing educational sessions at home.

In between retreats, there were frequent emails amongst group participants, allowing a chance for each dyad to share their successes and challenges as well as obtain feedback.

The second retreat offered opportunities to consolidate facilitation skills, learn about small group teaching dynamics, and more helpful sessions on developing simulation courses.

     1. Day 1: In addition to offering further opportunities to practice small group facilitation skills, this day offered an opportunity to do brief drills which isolated common challenges which learners might present (e.g. the learner who has difficulty identifying a learning goal, the anxious learner, the skeptical learner, etc).
     2. Day 2: More small group practice on small group dynamics issues (e.g. when learners are disruptive, etc). There were also sessions focused on course development (e.g. eliciting support from your institution, budgeting, etc).
     3. Day 3: This day focused on actor training, including an opportunity to practice training an actor for a new simulation.

Interspersed throughout the course were sessions which focused on educational theory, time for reflection on professional goals (as both a clinician and educator) and community development. By the end of the first retreat, it felt like we were part of a cohesive community, and distinctions between palliative care and critical care dissolved.

Because of the extent of non-ideal communication I observe on a daily basis in my practice setting, this has frequently resulted in a desire to prompt a sea change in practices. An “a-ha” moment for me as a participant was when I realized that this sea change cannot and will not come instantly under any circumstance. Sea change comes through identification of a personal “learning edge” and making one small change at a time (akin to continuous quality improvement). In addition, amidst the miscommunication, we need to provide ample positive feedback for things which learners already do well.

The teaching methods I learned through this course have already helped me better teach communication skills at my institution. The course played a significant role in the development of a local three day course for critical care fellows, led by my critical care colleague and me.

A nonprofit with the mission of nurturing healthier connections between patients and clinicians, VitalTalk continues to look for opportunities to provide similar faculty development programs for educators. Keep your eyes peeled for similar opportunities! You can sign up for email notifications from VitalTalk and follow them on Twitter (see their website: http://vitaltalk.blogspot.com/ ). Feel free to contact me with questions about IntensiveTalk.

For more information on the teaching methods, see Fryer-Edwards, K., et al. (2006). “Reflective teaching practices: an approach to teaching communication skills in a small-group setting.” Academic Medicine 81(7): 638-644.

Cheers,
Lyle Fettig, M.D.
Assistant Professor of Clinical Medicine
Indiana University School of Medicine
1001 W. Tenth St. OPW M200
Indianapolis, IN 46202
Pager- (317) 310-7988
Phone- (317) 630-7061
lyfettig@iupui.edu

Hospice and Palliative Medicine Visionary Warren Wheeler Shares His Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Warren Wheeler, MD, Senior Director of Palliative Medicine, Nathan Adelson Hospice in Las Vegas, NV.

Who has most influenced your work and what impact has he or she had?
As a medical oncologist in 1977, my patient Mrs. W. had gangrene of her lower extremities, a complication from metastatic breast cancer. She had horrific and uncontrolled malignant pain. I had been trained in medical school, internship, residency, and fellowship to treat the disease, not the person with the disease. As I and my house staff entered her room she was delirious and screaming from pain. Her two daughters stood at the foot of the bed and asked, “How can you let our mother suffer like this?” I was belittled in the presence of house staff, felt vulnerable, and inadequate as a physician. I owe it to this patient for changing my direction for caring of patients.

The first article I read on management of pain and symptoms in terminal illness was by Dr. Balfour Mount in his address to the Royal College of Surgeons of Canada. This opened my mind to a whole new area of learning. My next encounter was with Dr. William Lamers, Jr., medical director of Hospice of Marin. I completed his training seminar on ‘Developing a Hospice Care Team’.

Many pioneers of hospice have had a professional influence on my philosophy and knowledge on how to care for the chronically and terminally ill patients. Those physicians with major impact have been Drs. Eric Cassell (personhood), Ronald Fisher (day-care hospice of the NHS), Kathleen Foley (“The dose that works is the dose that works”), Cicely Saunders (principles of hospice philosophy), and Robert Twycross (whole person care).

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine?
To paraphrase poet Robert Frost, this is a lifetime affirmation that the hospice and palliative care road I chose has made all the difference in me as a person and in the care I give to patients. I have often thought how privileged it would be to have met Sir William Osler or Florence Nightingale. Well, I have the honor of living at the same time as their hospice counterparts, knowing and learning from them. This is truly an experience of a lifetime.

What is your vision for the future of hospice and Palliative Medicine?
My vision is that hospice philosophy and the principles of palliative care will be mandatory curriculum in all the professional schools of pharmacy, nursing, and medicine. The hope is that this will have a major influence on the minds of Americans who presently feel that they never die, but just underachieve!

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.

Community Inspiration

I want to express my sincere gratitude to the organizers and sponsors of the seventh annual Kathleen M. Foley Palliative Care Retreat and Research Symposium. This was my second time attending the retreat designed to provide a forum for interdisciplinary palliative care researchers. Participants include grant recipients from the National Palliative Care Research Center (NPCRC) and American Cancer Society (ACS), research scholars of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA), as well as other leaders in the field of palliative care. Once again, the meeting lived up to its reputation as one of the best for learning, collaborating, and developing new ideas.

Let me back up. I am a junior investigator with aspirations of becoming an independent palliative care physician-scientist. During the weeks prior to this year’s retreat, I had what was probably the first of many internal debates about my career choices. Let’s face it: academic medical careers can be daunting. I was struggling to reconcile my sheer conviction in my research with the realities of the current funding climate, personal fears of failure, and work-life balance. Put bluntly, I needed community and I needed inspiration.

Within minutes of the welcoming remarks, I thought, “Oh yes. HERE are my people. HERE is my inspiration.” And, that the sense of community and inspiration just kept coming. Whether it was the opening, middle, or closing plenary, I was glued to my seat, fascinated by the research (and frantically scribbling notes in the fancy notebook supplied by the venue). I watched my mentor (the incredible Joanne Wolfe) accept the American Cancer Society’s Pathfinder Award with grace, humility, and humor. She reminded me that all of us have similar struggles, but we also find great joy and gratitude in our work. During my own work-in-progress presentation, I solicited and received dozens of helpful comments and suggestions for continuing and expanding my own research projects. (In fact, I discovered yet another challenge in academic medicine: reigning in my own enthusiasm.) During a break-out session for pediatric palliative care researchers, we shared mutual pitfalls and successes in our research endeavors, providing yet more perspective of how to navigate my own career development. And, on top of everything else, I met several of my role models and other respected leaders in the field. I left with a renewed sense of commitment.

In retrospect, I realize the Kathleen Foley retreat has (again) succeeded in exactly what it aims to do. It provided a young investigator with a sense of community, inspiration, and purpose. I have no doubt the more senior investigators would say the same. I say again to the organizers and sponsors: “Thank you for this incredible opportunity.” I am already looking forward to the next one.

Abby R. Rosenberg, MD, MS (2012 AAHPM Scholar)

AAHPM Workforce Priorities

In June 2013 the AAHPM board approved the following priorities, including the addition of a senior level staff position fully dedicated to overseeing workforce, leadership, and academic initiatives for the Academy.

General

1. Addition of 1.0 FTE staff position (Director level) dedicated to workforce, leadership and Academic initiatives. One clear outcome of the workgroups is the recognition of the growing needs related to these areas. There is complexity with many stakeholders and much to gain with more Academy focus dedicated to workforce and leadership. This position would align one senior level staff person for each of the five strategic areas of AAHPM.

2. Assess and propose partnerships with other stakeholders (such as ASCO and AGS) to advocate for and promote educational innovations to address common workforce challenges, to partner on MOC activities, and to partner on data collection efforts.

3. Prioritize recommendations and develop implementation plan, timeline and clear delineation of assigned staff and committees.

4. Increase communication, information sharing and documentation related to certification requirements and fellowship training options with Academy leaders, members and between key contacts within external organizations.

5. Ensure ongoing workforce initiatives align with strategic plan goals and related governance structure.

6. Identify opportunities for increased engagement, collaboration and reporting regarding workforce issues and initiatives among Academy leadership (Board, SCC Chairs, senior staff and others).

Workforce Data & Health IT

7. Update existing workforce study with available projections (comprehensive study not necessary)

8. Conduct an assessment of currently available health information technology to increase clinical practice efficiency in HPM and meet regulatory expectations, including data collection and clinical decision support tools, as well as quality monitoring solutions. Conduct gap analysis and generate recommendations for new product development.

9. Identify data available in existing health information databases. Systematically review to ensure HPM inclusion

10. Gather information on post-fellowship trained physicians in order to track data and impact workforce

11. Enrich workforce information and practice data in AAHPM member profile/database, including if feasible and available, data from the 2010 salary survey

Maintenance of Certification and Alternative Pathways

Current Specialist Workforce

12. Provide effective member education about MOC, MOL, OCC including next steps

13. Develop two HPM MOC modules in at least three specialties (ABIM, ABFM, ABP) and ideally all 10; seek same with OCC. Sustain and grow the number of HPM subspecialists.

Generalist and Mid-Level Providers

14. Promote generalist level education to non-HPM specialists and mid-level practitioners including marketing of UNIPACS/Amplifire to hospitalists, geriatricians, emergency physicians, (for example) and mid-level providers.

Innovative Fellowship Models
15. Develop a document from AAHPM outlining the process and providing a template for obtaining the sponsoring board and the ACGME permission for an exception to allow a single individual to complete a fellowship half time over two years.

16. Propose to the ACGME a focused or full revision in program requirements to allow programs to organize to accommodate a fellow taking longer than 12 months, at less than full time. A focused revision would address ONLY the time taken to complete fellowship and allow less than full-time; a full revision would include the time element as well as a complete re-evaluation of fellowship requirements as is common with a new specialty after five years of review.

17. Work with the Veterans Administration to encourage the VA to develop, fund and implement an HPM fellowship structure geared to mid-career trainees that would meet the VA’s need for more certified HPM physicians.

18. Seek grant funding to develop and pilot innovative fellowship model as described in the workgroup charter.

19. Offer strategic and consultative guidance to mature hospices interested in developing or collaborating with fellowship programs. AAHPM role might range from suggesting opportunities (such as hospice providing salary support for medical directors seeking midcareer part time fellowship training) to technical assistance about meeting fellowship requirements.

The recommendations directly support Strategic Plan Goal B: Build Workforce & Leadership.
Objective 1: Monitor and address pertinent workforce metrics and gaps.

Objective 3: Increase exposure to hospice and palliative medicine through expanded training in all medical schools and within residency and fellowship programs.

Objective 4: Support the development of mechanisms and pathways for mid-career certification in hospice and palliative medicine.

Highlights of the November Issue of the Journal of Pain and Symptom Management (JPSM)

Listed below are a few articles from the most recent issue of the journal:

Breakthrough Cancer Pain: An Observational Study of 1000 European Oncology Patients
Andrew Davies, Alison Buchanan, Giovambattista Zeppetella, Josep Porta-Sales, Rudolf Likar, Wolfgang Weismayr, Ondrej Slama, Tarja Korhonen, Marilene Filbet, Philippe Poulain, Kyriaki Mystakidou, Alexandros Ardavanis, Tony O’Brien, Pauline Wilkinson, Augusto Caraceni, Furio Zucco, Wouter Zuurmond, Steen Andersen, Anette Damkier, Tove Vejlgaard, Friedemann Nauck, Lukas Radbruch, Karl-Fredrik Sjolund, and Mariann Stenberg

Targeted Investment Improves Access to Hospice and Palliative Care
Amy P. Abernethy, Janet Bull, Elizabeth Whitten, Rebecca Shelby, Jane L. Wheeler, and Donald H. Taylor, Jr.

The Cost-Effectiveness of the Decision to Hospitalize Nursing Home Residents With Advanced Dementia
Keith S. Goldfeld, Mary Beth Hamel, and Susan L. Mitchell

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847.375.4712 or visit aahpm.org.
Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Hospice and Palliative Medicine Visionary Timothy Quill Shares His Insights on the Field

In celebration of 25 years serving the profession, the American Academy of Hospice and Palliative Medicine (AAHPM) asked its 5,000 members to nominate who they think are the leaders – or Visionaries – in the field. They then asked members to vote for the top 10 among the 111 nominated.

“This program recognizes key individuals who have been critical in building and shaping our field over the past 25 years,” noted Steve R. Smith, AAHPM executive director and CEO. “These individuals represent thousands of other healthcare professionals in this country that provide quality medical care and support for those living with serious illness — each and every day.”

The Visionaries – 14 women and 16 men – are physicians, nurses and hospice pioneers such as British physician, nurse and social worker Cicely Saunders, credited with starting the modern hospice movement, and Elisabeth Kübler Ross, author of numerous books including the groundbreaking “On Death and Dying.” Five elected officials were nominated and one of them, former President Ronald Reagan, was named a Visionary for signing into law the Medicare hospice benefit in 1982.

Many of the visionaries will be sharing their thoughts about the field and who inspired their work. We’ll be posting them over the next several months. Today’s post is from Timothy E. Quill, MD FACP FAAHPM, Professor, University of Rochester Center for Experiential Learning in Rochester, NY.

Who has most influenced your work and what impact has he or she had?
My initial medical school interview was with Art Schmale who had trained as both an internist and a psychiatrist, and worked with George Engel. The University of Rochester’s biopsychosocial (and spiritual) approach provided a systematic structure to my training at the University of Rochester, but also is at the core of my two chosen fields of primary care and palliative care. I regularly rounded at the Cancer Center with Art as a medical student, where we would have wide ranging conversations with patients receiving treatment and their families, focusing on their symptoms, hopes, fears, and concerns – whatever was on their minds. I learned firsthand about the nature of suffering and of human resiliency. When I had finished my training in internal medicine, I did a Medical Psychiatric Liaison Fellowship in Rochester where we would address patients’ medical issues on the psychiatric floors and their psychiatric issues on the medical floors. All this was excellent preparation for a career in primary care, but Art also guided me toward also becoming a hospice medical director. Hospice was just starting out in those days, and we largely were flying by the seat of our pants without much data. I learned from Art about the extraordinary bond and connection that can happen when you join as a medical partner with patients and their families as they face very serious illness. That part of the work still fascinates and engages me now 33 years later, and is at the core of palliative care and hospice.

What does it mean to you to be named a “Visionary” in Hospice and Palliative Medicine?
Being named a “visionary” by my peers means a lot to me, especially since my “vision” has at times been controversial. I love the opportunity to partner with patients who are facing an uncertain medical future, and to commit to working with them no matter where that illness takes them. Most of the time with skillful application of palliative treatments, we can assist patients to find sufficient symptom relief and meaning throughout their illness through to their death. But there have always been a few patients whose suffering was much harder to relieve even with state-of-the-art palliative care. I have written about my struggles to address the needs of these patients, not to undermine the outstanding work that we do in hospice and palliative care, but to help us collectively figure out how to keep responding when our usual answers are insufficient. Although the commitment not to abandon such patients remains the core value, the particular answers I have come up with beyond that commitment to address these challenging situations are not elegant or ideal. Our patients and their families have no choice about going on this part of the journey if that is where their illness takes them; our challenge is to learn how to walk with them no matter where it goes. I am glad that our field continues to struggle with the edges of this vision, and I feel honored that the tent of the profession is broad enough to include me as one of its “visionaries”.

What is your vision for the future of hospice and Palliative Medicine?
Our program in Rochester like many others is growing like a “bad weed”. Perhaps we should have multidisciplinary palliative care co-manage every seriously ill patient throughout the country. But there are substantial problems with this vision. First, we do not have enough trained palliative care clinicians to do a fraction of this work. Second, even if we had enough clinicians, it is not a good idea to require an additional specialty team to provide all needed palliative treatments. Such an approach would not only be expensive, it would further fragment care and be non-sustainable. This has led to the proposal that “primary palliative care” skills be defined and taught to all clinicians who care for patients with serious illness, both primary care and non-palliative care subspecialists. Basic pain and symptom management and usual goals of care discussions would be carried out by those already providing the care (after a period of skill enhancement). “Specialty palliative care” would then be reserved for the more challenging cases (complex pain/symptom management, conflict over goals of treatment, major family distress) with the expectation that the patient whenever possible would be returned to the primary treating team for ongoing care and follow-up. As palliative care programs are starting up, trying to build and prove their worth, particularly in the current “fee for service” world, it may be difficult to make this broader vision a reality. But in a capitated world where real value counts, this integrated model of palliative care may well find a home.

More information on the Visionaries project, including the list of 30 Visionaries is on the Academy’s website www.aahpm.org.