In 2011, our burgeoning palliative care team had the unique experience to spend a week learning from the palliative care teams of McGill University.  During that week we learned about the Whole Person Care Program and subsequently invited the Director of Whole Person Care, Dr. Tom Hutchinson to Mayo Clinic to lead a workshop on Whole Person Care.  It was my pleasure to interview Dr. Hutchinson about the Whole Person Care (WPC) program at McGill.

Cory:  Please share with us, Dr. Hutchinson how the whole person care program at McGill got started.

Tom:   This history is important because WPC grew out of an insight from Palliative Care that subjective quality of life (QOL) could improve at a time when people are objectively becoming more ill.  That change to improved QOL during periods of worsening incurable illness is the process of healing. 

Cory: Tell me more about the relationship of WPC to Palliative Care (PC).

Tom: What PC did in taking care of incurable people was that they rediscovered the process of healing.  Dr. Mount and Dr. Kearney are largely responsible for this rediscovery.

In 1999, they set out to reincorporate the process of healing into the medical mandate.  It had been lost track of.  We need both the medical science and the healing relationship; whole person care.   The approach has been through transforming our approach to training our medical students and faculty and our relationship with the people of Montreal.

We have two main approaches.  First with medical students they have a mandatory WPC curriculum that aims at teaching them tactics to provide a space for healing.  Our hope is that McGill is producing physicians better able to incorporate a healing approach into their medical practice. Courses in the existential aspects of medical care are taught and mindfulness and meditation are offered as vehicles to facilitate a healing presence.

We also train our faculty so that there is an environment that is receptive to a healing approach where students can grow and develop.

Students are partnered with their faculty mentor for a mentorship process called physician apprenticeship.   There are six students for one faculty for the entirety of medical school.   Burnout is a significant entity in medicine.  We have started to teach mindfulness for self-care and presence with patients.

We have engaged the public as we recognize the yearning of the general public for WPC.  They are essential allies in the promotion of WPC.  To capture their interest we have developed two forums to explore healing.   Firstly, we have developed a film series in which films illustrating the process of healing are viewed and a dialogue is held after the film.  The films are well attended.

We also offer a seminar series with a similar purpose.  These are invited lectures on topics like empathy, hope, or other topics related to WPC. 

Cory:  I understand you are going to expand your influence to host the first ever international congress on WPC starting in the fall of 2013.

Tom:  That is right.  This conference will be held every other year in Montreal.   The focus of the conference is to address how we can change the medical mandate to incorporate WPC.  This will be a full breadth academic conference to cover topics such as mindfulness, narrative medicine, and methodology to change systems to incorporate WPC in to the standard practice of medicine.

Cory: This last spring you edited the first textbook on WPC.  Can you tell us about the book?

Tom: The book attempts to put together the contributors to WPC from McGill and around the globe.  It attempts to develop through 18 chapters the concept of WPC from different aspects and approaches.   It covers topics from genetics to medical teaching, and concludes on professionalism at McGill.  The last chapter lifts the veil and peeks at the future of WPC as a renewed focus on the relationship between the doctor and the patient.  That relationship has both an empathic component and includes medical expertise that the patient doesn’t have.   Along with that is the mutual respectful relationship and mutual vulnerability to treat them as a whole human being.

I think this is going to happen because this is what doctors really want and why many went into medicine.  And it is what patients really want. Medicine is more effective than ever before but somewhat less attractive due to the loss of the approach to healing.  A rediscovery of what is important to doctor and patient and gives satisfaction to both parties within the relationship. 

Cory: Since WPC grew from lessons learned from PC, how will WPC and PC relate to each other going forward?

Tom: PC remains the best model for WPC that we have.  PC is important as an exemplar of WPC.  There is a risk that PC may become a more fixing, curing discipline and forget the healing aspect.  PC has to remain the model for healing.  PC needs to represent WPC for the rest of medicine.  PC is a new way of looking at medicine that can change the rest of medicine.  It will have a strong relationship with WPC.  PC is a beacon for a different type of care.

Cory: How does PC maintain their skill, role and time in the changing health care landscape?

Tom: Not a simple solution.  The more we turn medicine into an enterprise that is financially driven and primarily an industrial model of efficiency and cost effectiveness this will be unhelpful for medical practice.  What these approaches do is focus on products and forget the reasons for what we do.  A model that focuses on efficiency has different effects that particularly may divert away from processes that lead to healing.  There is a momentum to the industrial model.

After speaking with Dr. Hutchinson, I can’t help but wish my medical school had had a similar curriculum with attention to WPC.  Fortunately, there are ongoing opportunities to learn from the wealth of experience at McGill.  I hope to attend the 2013 first international conference on whole person care.  I have already read the book and given a copy to each palliative care team at Mayo within the Midwest. 

Cory Ingram, M.D.
Assistant Professor of Family Medicine and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Medicine
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

Formal training in self-care is relatively uncommon in most medical disciplines.  Hospice and Palliative Medicine (HPM) specialty may be the exception.  Grief if left unnamed can be a source of great pain, and as with any wound, if ignored, runs the risk of festering only to cause even greater discomfort and distress.   

Granek et al published a revealing qualitative study earlier this year establishing patterns of grief responses to patient loss among oncologists as negatively impacting both their personal as well as professional lives¹.  Some of the impacts included worsened emotional irritability and exhaustion as well as the potential for altered patterns of care for future patients in an effort to shield themselves from further pain.  Many study participants described their coping mechanisms as one of distancing and denial.  Importantly, participants commented on their awareness of these impacts but had no access to altering their behaviors.  In fact, several physicians stated this was the first they had ever spoken openly about these emotions due to the taboo of being unprofessional in the medical community.   

Perhaps no different from traditional wound care, exploring the depths of grief, risking heightened pain temporarily in favor of providing optimal exposure, may allow for the greatest potential to heal.  By actively creating dialogues with colleagues and openly expressing our feelings of connectedness to our patients and families, this acknowledged closeness and care becomes a natural path to grieving in a supportive environment.  In fact, it may provide integrated self-care practices offering enhanced resilience and job satisfaction².

An opportunity for culture change is at our doorstep.  With the recent new policy statements issued from the American Society of Clinical Oncology calling for integrated palliative care from the time of advanced cancer diagnosis, and enhanced doctor-patient communication regarding end-of-life care³, an opening for HPM collaboration offering supportive coping and self-care strategies for oncologists is possible.  In the past year at UCSF, a portion of our formal curriculum on self-care in the Division of Palliative Medicine has been piloted within the Medical Residency training program with very favorable feedback.  We are now in the process of rolling out a program with the UCSF Division of Hematology and Oncology.  

Acknowledging loss can take form in countless ways with varying degrees of time commitment.  In addition to creating communal condolence cards for those we have served, the UCSF Division of Palliative Medicine has an annual Day of Remembering where families and clinicians come together and openly share stories of grief and love invariably mixed with tears and laughter.  What would be possible if clinicians in all specialties were afforded an environment that embraced relationships with our patients with a natural response of grief at the time of loss?  What is more human than acknowledging missing someone we have cared deeply for?  Perhaps the promise of remembering our patients is the greatest hope we can offer.

References :
¹ Granek, L et al.  Arch Intern Med 2012,172(12):964-966
² Mack JW and Smith, TJ.  JCO August 1, 2012 vol. 30 no. 22 2715-2717
³ Smith, T.J. et al.  JCO Published online before print February 6, 2012, doi: 10.1200/JCO.2011.38.5161

Dawn M. Gross MD, PhD
University of California, San Francisco
Department of Medicine/Division of Hospital Medicine/Palliative Care Service

by Larry Beresford

The most comprehensive assessment of the hospice and palliative medicine (HPM) workforce shortage, conducted by Dale Lupu for AAHPM’s Workforce Task Force in 2010, estimated a gap of between 2,787 and 7,510 FTEs just to satisfy the current need for HPM physicians.[1] And that doesn’t count the coming tsunami of aging Baby Boomers with multiple chronic conditions—or the looming retirements of many of the field’s leaders and pioneers.

The current pipeline of new fellowship-trained HPM physicians adds fewer than 200 new specialists to the workforce each year—with structural constraints on its growth. After this year’s HPM board certification exam in October, the experiential pathway to board certification for mid-career physicians will come to an end. And that is why the Mid-Career Training Task Force convened 43 experts and leaders of the field at the Westin O’Hare Hotel in Chicago August 9 and 10 for a summit designed to grapple with the workforce dilemmas and consider possible future scenarios for this field.

Where is the field of HPM going? Will it continue to experience growth? What will be the impact of an anticipated 4,000 new board-certified HPM doctors following this year’s exam? How does HPM fit into the reforming health care system of medical homes and accountable care organizations? How might the field evolve, revise its focus or even change its name to keep up with those larger changes? Should the focus of AAHPM be narrowed or broadened? If there is a limited resource of HPM specialists, can primary care physicians be taught to play larger roles in providing primary-level palliative care to their patients? What about nurse practitioners and physician assistants? What are best practices in a world where there will never be enough HPM practitioners? What kinds of mid-career alternatives might be envisioned to the full-year, full-time fellowship that will be required for new HPM physicians starting in 2013?

These are the kinds of questions that were explored at the Workforce Summit. National leaders like Norman Kahn, MD, executive vice president, Council of Medical Specialty Societies; Clese Erikson, MPAff, director, AAMC Center for Workforce Studies; and William Iobst, MD, vice president of academic affairs, American Board of Internal Medicine, offered insights, hope and useful suggestions and believed that a mid-career solution was at least theoretically possible, working with ABMS and other specialty societies. But first, it is essential for AAHPM to clarify the need — both currently and in anticipation of future need — and craft a proposal.

Clement Bezold, PhD, founder and chairman of the Institute for Alternative Futures, served as a facilitator, helping participants to engage in future scenario planning, which he acknowledged is an uncertain process. “It’s not about prediction but preparation,” he explained. “Success is the degree to which your current thinking changes.” Participants in small groups explored four possible future scenarios for the field, with his charge: “If this is your future, step into it.”

Congratulations to Academy leaders including Workforce Summit co-chairs Amy Abernethy, MD FACP FAAHPM, David Weissman, MD, and Mid-Career Task Force Chair John Mulder, MD FAAHPM for organizing and framing such an important discussion.

Since 2009, The Center for Innovation at Mayo Clinic has hosted a unique blending of design and medical professionals to hold a 3 day dialogue, at a deeper level, on innovations that shape new ways of providing medical care with over 8 countries and 21 states represented.  There are over 125 businesses in attendance.  As an iSpot awardee for our transformative approach to Palliative Care known as The Personal Caring Initiative, I sat down with members of the Center of Innovation(CFI) at Mayo Clinic to talk about Transform 2012: The Conversation will Continue, September 9-11, Rochester, Minnesota. 

Cory: First of all, thank you for the iSpot award, I am very grateful and humbled with this award.  I am new to transform and I understand it is really cool.  Perhaps you can share why “Transform” and why is it cool?

CFI: As a very small team over the last few years, the vision is for transforming the experience of healthcare and to disrupt the status quo.  Transform brings in people from many disciplines from outside medicine to collaborate about new care deliver models.  Transform is an environment for ideas and inspiration.  At the core, Transform is reaching beyond medicine to understand health.   It is described as a passionate, energetic, excited, and nontypical medical conference.  It is in the space between medicine and design.

Cory:  I remember my mentor commenting that we can’t change health care by changing health care but rather, we have to mature our culture and transform our communities.  I understand that this year Transform is calling out one elephant in the room that has been considered politically radioactive and a major source of misguided rhetoric in the media, namely, end-of-life care. 

CFI:  Two elephants are being brought out; End of Life Care and Teenage Suicide.   We hope the elephants that come storming out will allow us to look differently at other elephants in our institutions and culture.   Michael Wolf, journalist, is a panelist on the Elephant in the Room speaking on his experience with his mother’s medical care as illustrated in his New York Magazine article,  A Life Worth Ending.  Dr. Satow, is speaking on Teenage Suicide and his creation of the Jed Foundation in honor of his son. 

Cory: Why end of life care?  In fact, Mr. Wolf’s article was very controversial.  It seems a bit risky?

CFI: It is a risk.  It is a testament to CFI to be a disrupter of the status quo.  We pick things you wouldn’t expect.  This will resonate with the personal connection of people within Transform.  They have been through this. You want this to blend into the everyday fold of their life.  Leslie Koch will speak on the Governors Island story as an example of the something unexpected and an extraordinarily novel and relevant approach to transformation.

Leslie Koch, President of The Trust for Governors Island, is using a very experimental planning model to re-design something very big. She is overseeing the planning, redevelopment and ongoing operation of the Governors Island transformation in New York Harbor. Under her leadership, the island has been a place for experimentation with the end goal of becoming a vibrant public space for New York. She is approaching this project very openly, transparently and using a very experimental model, essentially co-creating the redesign of this property with visitors and citizens of NYC; people that will use the park. Imagine if we approached transforming health care in such a way, or at a micro–level, transforming the Palliative Care model.  Going to the users — the patients and family of receiving Palliative Care — to discover new and transformative approaches we can use to care for people and their families living with serious illness and possibly approaching the end of life. Approaches that we may never even have considered on our own. Ultimately creating a care model that provides greater value and better outcomes to the patient and family — much more than an office visit that we sandwich in between visits that can range from ingrown toenails and annual check-ups. The needs of the patient come first, and a holistic model is the healthiest for touching all palliative patients.

Cory:  I am getting the sense that Transform is more than the 3 day dialogue? 

CFI:  What happens at Transform comes back to the CFI to help us understand things differently.  Dr. LaRusso has been pioneering this to bring forth the best solutions.  Transform is a continuous conversation and connections with attendees throughout the years.  The narrative of attendees is that this is a non-traditional conference. 

I think the excitement around new ideas and collaborations is a driving force around people wanting to come.  They are not satisfied with the status quo and want to impact the lives of people.  We are proud of weaving design into health care. 

I am very proud to be allowed to participate in Transform 2012 as an iSpot recipient for our work on The Personal Caring Initiative.  I envision The Personal Caring Initiative as a model of care that offers hope for our culture and our society as a paradigm shift towards comprehensive tender loving human to human care to our most frail among us affirming life, all of life, including the part called the end of life.    It is my hope that there will be a connection created between the AAHPM and Transform to thoughtfully continue to mature and transform our culture, communities and delivery of the best care possible for seriously ill people and their families.

Cory Ingram, M.D.
Assistant Professor of Family Medicine and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Medicine
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System

This year McGill will host the 19th International Congress on Palliative Care(ICPC) founded by McGill’s Emeritus Professor and Father of Palliative Medicine in North America, Dr. Balfour Mount. The congress is chaired this year by Dr. Anna Towers. This conference represents the oldest conference in the field, and is led by Dr. Bernard Lapointe, Eric M. Flanders Chair in Palliative Medicine and Director of Palliative Care at McGill, with whom I spoke to better understand what attendees could expect from their pilgrimage to Montreal this October 9th-­12th.
 

Cory: Thank you or taking the time to talk with me about the International Congress on Palliative Care. What makes the ICPC so special?

Bernard: It is a continuation of the vision of Dr. Balfour Mount, who founded the first ICPC in 1976 featuring Elizabeth Kubler-­‐Ross, Dame Cecily Saunders and Dr. Mount himself. Secondly, the congress is truly international with over 60 countries and all continents represented all coming together to share their visions on PC. The conference is bilingual with presentations in French and English. Lastly, what sets this conference apart is that we dedicate time for interdisciplinary dialogue, questions, and interaction. We pride ourselves in providing a time rich learning environment that allows for presentation and dialogue. It is truly interdisciplinary, and offers the current status of international PC with 400 posters and 260 presenters from around the world.

This year particularly, we have special sessions on pharmacology, the arts and humanities, volunteers, and architecture. The congress remains the largest venue for pediatric palliative care with two full days dedicated to pediatrics for those interested.

Cory: In celebration of the 45th anniversary of St. Christopher’s Hospice, how are you intending on spotlighting St. Christopher’s?

Bernard: This year as well we will spotlight St. Christopher’s and their 45-­‐year anniversary. Most interesting, Dame Barbara Monroe will speak on the history and lessons learned at St. Christopher’s and provide a glimpse of the future of PC at St. Christopher’s. The design is that the spotlight will start with a plenary and then a series of workshops.

Cory: I can only imagine that another highlight from the conference will be the closing plenary from Dr. Balfour Mount, On Healing.

Bernard: This will be a fabulous presentation from Dr. Mount that will serve as an overview of his career and his contribution to Palliative Care. I am looking forward to attending the International Congress and from talking with Dr. Lapointe, I have visions of an experience that will connect with rich history of PC at McGill and St. Christopher’s at the same time showcasing the most recent developments in an international interdisciplinary forum. Not to forget, Montreal is a beautiful and delightful fall destination.

Well, the board review course is complete and many of you are now beginning your studies in earnest. For many of you, it may be the first test you have taken in a number of years.  While there is never a substitute for knowing the material, brushing up on your test-taking skills can give you that extra edge.

Bruce Chamberlain, MD has completed an excellent slide presentation on Test Taking Skills and Strategies for the HPM Board Exam. Some pointers include:

• Never get “hung up” on one tough question. Skip it and come back to the question later. Sometimes later questions can provide hints to the answer.
• Answer all of the questions. There is no penalty for guessing.
• Always determine what the question is really asking. Don’t try to insert your “real world” experience.
• With long questions, skip down to the actual question. This can help you focus your approach to the information.

The majority of questions are based on patient presentations occurring in settings that reflect current medical practice.

Remember. Take your time!  What do they call the last person to leave the test with a passing score? Board Certified!

Good luck!

Vincent Vanston, MD FAAHPM