American Pain Society Meeting

I attended the first two days of the American Pain Society Annual Scientific Meeting in Tampa, Florida. It is a big affair, over 1300 people. I was quite impressed by the quality of the speakers--not just the the content of the presentations, but the speakers were, for the most part, good presenters.

The most prevalent recurring theme in the clinically oriented (as opposed to the basic science) presentations was the issue of prescription opioid abuse. It got a bit wearisome after awhile, perhaps because I presented on the same topic at the Nursing SIG session! Kinda reminded me of a recent cautionary comment by Kathy Foley at another meeting that pain management is being eclipsed by risk management. The most controversial session, on the Washington State opioid guidelines (see previous mention), was well managed and avoided descending into a shoving or shouting match. I'm still left unconvinced that the identified problem (an increase in opioid-related deaths in workman's comp patients) will be solved with the institution of the guidelines. They have been identified as a pilot and an educational endeavor, but one person from the audience said that he had been denied insurance payment for a patient on opioid doses greater than 120 mg unless additional justification was provided (perhaps an inevitable and predictable but unintended consequence). The "education" is being provided by the medical director for the department that handles workman's comp. He was obviously well-meaning and very concerned about safety issues, but he is not a pain specialist, and as far as I could tell, had no special training or experience in pain management.

The exhibit hall also had it's share of substance abuse-related products and give-aways. There were several urine toxicology companies there and multiple free "risk-reduction" education pieces, all sponsored by pharmaceutical companies.

There was an entire session (which I did not attend) on new tamper-resistant formulations of opioids.

Other new products and products in clinical trails of interest to this readership: Subcutaneous methylnaltrexone (Relistor) for opioid bowel dysfunction (see previous post); an oral form is just entering phase 2 trials; a pegylated oral form of naloxone is just entering human trials; an oxycodone-morphine combination tablet has just completed its first phase 3 trial; a sustained-release hydrocodone-acetaminophen tablet has completed a phase 3 trial; a cannabinoid is approaching clinical trials. Most of you are probably aware that there are new dosage strengths of OxyContin (15, 30, & 60 mg), and that all of the generic CR oxycodone products are off the market. There are also new dosage strengths of oxymorphone ER (Opana ER; 7.5, 15, & 30 mg).

There was a lot of exciting new basic science regarding pathways, receptors, neurotransmitters, and other cool stuff that was mostly over my head, but by implication provided new therapeutic targets.

One of the most interesting sessions was on rational approaches to multidrug treatment of neuropathic pain. It's all about patient assessment and pharmacokinetics.

On to the nursing (American Society for Pain Management Nursing) pain meeting in the fall!

Peaceful acceptance of cancer; Chemo neuropathy; 'Slow medicine'

Two from Cancer:

1)
First is a paper discussing a scale developed to measure peaceful acceptance of a cancer diagnosis. This comes from the Coping With Cancer Study (previous publication here) and the paper describes the development and some of the validation of their scale ('PEACE') which attempts to measure both 'peaceful acceptance' of an illness (e.g. asks things like To what extent do you feel you have made peace with your illness?) and 'struggle with an illness' (asks about what extent a patient feels their life is over as they now know it, what extent they feel it's unfair they have cancer, etc.). They also give some of the findings of the CWCS that I'll note.

First they found that answers to a single item on the peaceful acceptance subscale (to what extent do you believe a sense of inner peace and harmony?) strongly correlated to the entire peaceful acceptance score (i.e. it could be used as a quick and dirty substitute for it). They also report that patients' self-reported awareness of having a terminal illness (all patients in the study had advanced/incurable cancer) was not related to peaceful acceptance of their illness (peaceful acceptance scores were similar between those who acknowledged or didn't acknowledge being terminally ill). (This is similar to findings they reported in the prior publication I mentioned above.) They did find however that patients' reported 'struggle' with an illness was higher in those with a terminal illness acknowledgment (as were, interestingly, rates of advance care planning & living will completion). As you'd expect, reporting being strongly 'spiritual' had a protective effect all around. Higher symptom scores were associated with lower peaceful acceptance and higher struggle.

The conclusion I'd love to make from this is that we have it right in palliative care: honest disclosure of prognosis/terminally ill status doesn't 'hurt' people, symptoms do, so let's keep on telling the truth and treating symptoms. This is one study of course, and I shouldn't overplay these results, but I think from a didactic/rhetorical standpoint it is helpful/welcome to behold some data suggesting that knowing your prognosis doesn't affect your ability to feel peaceful about your condition/lot in life. (These were of course people who freely acknowledged/admitted to having a terminal illness - one wonders how many of them were told this or just figured it out for themselves.)

Of course there's more struggle, but of course there is, and one cannot take away the 'human condition part of the human condition,' so to speak. I think I've blabbed on this blog before that I think the CWCS is one of the most interesting recent research projects out there; it seems to me to be a big leap forward in this type of research (understanding how/why terminally ill patients understand, cope with (or not), their illness and how that affects the sort of care they get) and I hope there will be further publications from the study.

Mack, J.W., Nilsson, M., Balboni, T., Friedlander, R.J., Block, S.D., Trice, E., Prigerson, H.G. (2008). Peace, Equanimity, and Acceptance in the cancer experience (PEACE). Cancer DOI: 10.1002/cncr.23476

2)
Second is a randomized, controlled trial of lamotrigine for chemotherapy associated peripheral neuropathy. It involved 131 patients (mean age 61 years; about 2/3 had finished their chemotherapy) with painful chemotherapy induced peripheral neuropathy with at least 4/10 pain; they were started on lamotrigine (titrated to 150 mg bid over 8 weeks) or matching placebo and were followed for 10 weeks total (only two weeks on the max dose). The results weren't good for lamotrigine: pain was a little better in both groups and both primary and secondary pain outcomes were identical between groups. Lamotrigine had more side effects and more drop outs due to them (this approached but didn't reach statistical significance).

A couple things here: people weren't on the maximum dose of lamotrigine that has been studied and shown to be effective (at least 400mg), however there really was not even a hint of a dose response curve here - it's not that lamotrigine looked a little better but didn't achieve statistical significance - lamotrigine's curve never departed from placebo's (actually it looked a little worse for a bit). I don't use lamotrigine and I'm not sure if 2 weeks on the max dose is enough; however the total time on active treatment was 10 weeks without a hint of benefit (and if this drug takes more than 10 weeks to work is this something we'd want to use anway?).

This did get me thinking: what are people using out there as the 2nd line antiepileptic adjuvant (after gabapentin or pregabalin which I'm assuming most people are using - one or the other - as their 1st line AED adjuvants)? It also got me thinking: has anything been shown to be an effective therapy for painful CIPN (in a controlled trial)? EPERC recently published this Fast Fact about it and my recollection when I was editing it is that there's a dearth of controlled data.

3)
The New York Times has a story about 'slow medicine,' focusing on a care-model being developed at a nursing home in New Hampshire. 'Slow medicine' really means deliberately and pro-actively defining care-limitations up front in elderly patients in light of their goals and prognosis (i.e. it's also 'good medicine' and shares palliative care's ethos of 1) honesty about prognosis, 2) focusing on care goals, and 3) explicitly giving people all their care options including limitations on testing/hospital level care/etc.). This is a really telling excerpt:

Kendal begins by asking newcomers whether they want to be resuscitated or go to the hospital and under what circumstances. “They give me an amazingly puzzled look, like ‘Why wouldn’t I?’ “ said Brenda Jordan, Kendal’s second nurse practitioner.
She replies with CPR survival statistics: A 2002 study, published in the journal Heart, found that fewer than 2 percent of people in their 80s and 90s who had been resuscitated for cardiac arrest at home lived for one month. “They about fall out of their chairs when they find out the extent to which we’ll go to let people choose,” Ms. Jordan said.

"Fall out of their chairs...": apparently these patients weren't used to being offered options/choices about their care.

Thanks to Kathleen Jacobs, RN for alerting me to this article.

L'Envoi by George E. Ehrlich

The following essay was first published in Prognosis: Contemporary Outcomes of Disease, published by Charles Press, 1981. Permission granted from Dr. Ehrlich to reprint on Pallimed.

Prognosis is the essence of Medicine. It gives purpose to diagnosis and helps the physician ascertain what might happen and decide what ought to be done about it. It lends rationale to treatment. All therapeutic decisions, the popular cost-benefit ratio, and various equations that determine choices are based on what we understand about prognosis. It is bewildering, then, that prognosis receives only passing mention in the disease descriptions found in most textbooks and that its study has not yet been dignified by designation as a major scientific discipline.

And yet this should come as no surprise. The forbidden kernel in the gift of Prometheus was foreknowledge. Adam and Eve were expelled from Eden because they wanted to know what would happen next. Primitive instinct, which causes animals to respond with fear and flight, detects the danger without understanding it; only Man seeks to scan the future. Prognosis is the forbidden fruit and its pursuit is cloaked in magic. Laocoön perished with his sons in its service, and the gods assured Cassandra's warnings would not be heeded. Logic could infer that it was not too much to expect that the victorious general, Macbeth, would be awarded the traitor's earldom and an elective kingship upon death of the elderly Duncan; voicing the obvious could not come from Banquo or Macduff, however, but had to be pronounced by the three mysterious witches. Three sisters - the magic number: an exclamation point lest one not realize the terror implicit in knowing the future.

To learn what would be, Wotan was willing to sacrifice an eye. The malign, one-eyed Hagen was able to capitalize on this distinctive physical similarity to dominate the Nibelungenleid and to become the instrument that determined future events. The pallid Siegfrieds haven't a chance - the present is ephemeral, the future vast. Mephistopheles, Iago, Edmund, and Goneril and Regan - the villains move the piece and fascinate us - their actions become their prognosis. Alfred North Whitehead proclaimed that "It's the business of the future to be dangerous." The more one understands what the future will bring and the more one sees what might be, the more rationally one can behave. Early caveman developed society to aid in withstanding the rigors of existence and he developed agriculture because inclement weather was to be expected. Survival depended on the understanding that putting in stores during the good years and the good days would anticipate the bad. The dream of Joseph saved the peoples of the Mediterranean litttoral. Long before, hunters learned to follow spoor that would lead them to their prey, and the development of this ratiocination determined the optimal place to settle in order to survive. Like Brigham Young, they could say with certainty, "This is the place."

The pursuit of knowledge of the future comes dear and the knowledge itself dearer. The man that once did sell the lion's skin/while the beast liv'd was kill'd with hunting him," says Henry V. Croesus sought to know whether he ought to oppose the might of Persia or offer tribute. The Oracle informed him that, if he went to war, he would destroy a mighty empire. Thus emboldened, he fought the Persians, only to see his own empire destroyed. In reading the future, one must be certain not to be misled. Santayana warns that not to know the past is to be condemned to repeat it. I prefer Aubrey Menen's studious locust, as he became enlightened in the irreverent retelling of the Ramayana: "After titanic study he was satisfied that a thorough knowledge of the past could lead a profound scholar to predict the future course of history with great accuracy provided that it does not turn out quite differently."

The annals of prognosis are cloaked in mystery and feature a faintly disreputable cast. From the Witch of Endor to Nostradamus, from Heraclitus to Spengler, from Confucius to Malthus, being able to see more clearly assures immortality and hostility in equal measure. Yet the capacity to understand the future helped to create Man. The sibship of the correct prognosticator survived to become our ancestors. It is the knowledge of the future that is powerful medicine and thus it is of the Medicine Man that the tribe stood in awe. Empirical observation produced the skill. But how many pharaohs had to undergo trephining of their skulls because it once relieved the intracranial pressure in one?

The responsibility the physician assumes is great. The Ius Talionis saw to it that risks attended the rewards. The physician who cost the patient an eye suffered the loss of his hands. Codified by Hammurabi, the balance implies a sureness, a guarantee, that we have not achieved to this day. Scribonius made the doctor a productive servant of God from whom all healing comes and who imparts to medicines their power. Immortality was longed for, but mortality assumed. Maimonides set the span of life at one hundred and twenty years and argued that it was man who shortened it. How prescient, as Hayflick's cell division gives a figure only slightly lower! Can we determine the factors that shorten life in order to conquer them? Empiricism and the combination of simplistic holisms have given us a start in that direction. But the mischief of irresponsible prognostics is still with us and the task of sorting out only just begun.

The modern science of prognosis is based on analysis of groups of people. In most instances, it is not yet possible to extrapolate from the general to the specific in order to arrive at a correct prognosis in a single instance. Obviously it is more important to the patient to know what is going to happen to him than to know that eighty or ninety percent of people like him fare a certain way and the remainder another. Right now prognostication is based on probabilities, but perhaps this book will serve as a start toward a more active search for prognosticators that better characterize the individual. Γνϖδι σαντον, said the Greeks; "Know then thyself and seek not God to scan, the proper study of mankind is Man," echoed Pope. It is the certain knowledge of the future that separates the godhead from Man, and it is the pursuit of that knowledge that ennobles Science. And yet there is just the element of chance that must remain: . . . . "We doctors know a hopeless case if - listen: there's a hell of a good universe next door; let's go!"

Evidence and palliative care; hydration reviewed, sort of; opioid antagonists for OBD

1)

Over here at Pallimed we’ve been having an off-line conversation about “evidence” for palliative care-related practices, and decided to bring it to our readers. The impetus for the discussion is the publication of two new Cochrane reviews, one on medical hydration in advanced illness and the other on mu-opioid antagonists for opioid-induced bowel dysfunction.

Regular readers of Pallimed will know that the three of us are strong proponents of increasing and improving the evidence base for palliative care. We are also very much aware of the difficulty of doing so, especially using the stricter definitions and methods of evidence-based medicine (EBM).

I will disclose that I am not a regular devotee of the Cochrane reviews, but “medically assisted hydration” caught my eye. I was disheartened, however to see that only 5 papers made the cut to be reviewed, and that the conclusion was “There are insufficient good quality studies to make any recommendations for practice with regard to the use of medically assisted hydration in palliative care patients.” It reminded me of a conversation a couple of years ago with a well-known pain physician and researcher. He told me that he doesn't even read Cochrane reviews anymore. "They all end with the same conclusion: there is insufficient evidence to make a recommendation about . . . " I don't think that is necessarily a bad thing, but they are super-strict in their criteria for selection. That makes it particularly difficult in palliative care, where doing the type of research one might do for approving a hypertension agent is almost impossible. The issue, of course, is that the assumed “highest” level of evidence is the randomized controlled trial (RCT). Some have argued that RCTs are not only difficult to design and conduct, but may be unethical in interventions for people with advanced disease where comfort, not cure or control, is the therapeutic goal. Others criticize the misuse of EBM, either attempting to apply broadly the results from a trial in a subset if patients, or conversely denying payment for a successful intervention for a specific individual because the RCT “proves” that the intervention doesn’t work. Fragile patients with advanced disease are usually excluded from RCTs, yet that is precisely the population most in need of evidence-based palliative interventions.

The phrase “perfect is the enemy of good” springs to mind. But the RCT is unlikely to ever be the “perfect” tool for symptom management, population-based or public health studies, and other complex beyond-the-physiology questions.

Carr, an early proponent, points out that EBM continues to evolve, has limits, and can easily be misused. Where applicable, the RCT should be used, but with the results interpreted judiciously for specific populations and individuals. Hallenbeck, Carr (specifically for pain medicine), Aoun & Kristjanson, and Devery are among those who have made reasoned criticisms of EBM, and suggested “other ways” of using EBM or of gaining knowledge. These include an “Equity-based evidence framework” (Aoun & Kristjanson), “narrative-based” evidence (Devery), or recognition that “lower” (not necessarily less rigorous) levels of evidence apply quite well to palliative care.

We’d like to hear how our readers use and interpret “evidence” in their practice of palliative care.

2)

Getting back to the Cochrane reviews:
Hydration: there was only one “high quality” study (2 RCTs) but over a very short duration (2 days) and very underpowered. Overall, results of the 5 studies reviewed were somewhat contradictory, but showed suggestions of improvement in sedation and myoclonus. Negative effects cited were fluid retention leading to peripheral edema, ascites, and pleural effusion. In their conclusion, the authors acknowledge the difficulty of conducting clinical research in the palliative care population. They also comment “the issue of medically assisted hydration in palliative care patients causes such divergent views, yet there are so few studies to guide clinical practice properly. As well as looking at further RCTs in this area, the evidence base will be improved with at least more prospective controlled trials.” It should be noted that the "best" study had quite a few patients with reasonably good performance status, especially in the intervention group. It was not really helpful, therefore, in answering the question: "is medically assisted hydration a helpful intervention in patients in the last days of life?" One of the included studies, a prospective controlled trial, attempted to mimic real world decision-making by allowing physician preference in allocating to the intervention arm. This introduces bias,of course, but downgrading the score on the study design because of it may make some clinicians grind their teeth. The whole point in reading a study is to find help in making real world decisions, isn't it? That raises questions for a future conversation.

Opioid antagonists for opioid-induced bowel dysfunction (OBD):
Naloxone, nalbuphine, methylnaltrexone, and alvimopan were reviewed. There was only one study of nalbuphine. All studies were placebo-controlled RCTs (which makes sense in this case; active-controlled studies would also be welcome). Some studies of the newer agents (methylnaltrexone & alvimopan) were in healthy volunteers. The authors report that their task was made more difficult by use of various opioids in trials, and by inconsistent definitions of postoperative ileus. In general, though, they found (in a limited number of studies with small numbers) that methylnaltrexone and alvimopan were sufficiently safe and effective (increased transit time/decreased constipation) to be labeled “promising.” It should be noted that methylnaltrexone was administered parenterally in these trials, and that oral methylnaltrexone has yet to be reviewed. Alvimopan trials were interrupted because of excess cardiac events. The current target indication for alvimopan (not yet approved) is postoperative ileus.

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Just as an aside, the last author on this review is Dan Carr, cited above in the EBM discussion.

There is another recent review here.

A just-published RCT was not part of either review. Subcutaneous methylnaltrexone (Relistor) was approved by the FDA last week for patients in late-stage advanced illness and should be available next month.

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So, who among our readers is waiting impatiently for methylnaltrexone to become available? Given the route, cost, and limited research, are you eager to give it a try? In general, are we adequately treating opioid-induced constipation, but need this for backup? How will you determine which patients receive it? How many other interventions do you need to go through before you determine that constipation is refractory to more conventional treatment? Oh, and do any of you actually use the newly minted term 'opioid bowel dysfunction' (OBD)? The Comments link awaits you.

Head & neck cancer; Vitamin D; Do not 'METuscitate'; More

Many items....

1)
From JAMA:

First is one in their ongoing series 'perspectives on care at the close of life' on palliative care for patients with head & neck cancer. Besides being a solid review of the topic, as are most of the 'perspectives' pieces, this one stood out for two reasons. It's the most 'supportive care-y' one in this piece, and really reflects a broad perspective of palliative care as not just for the dying (despite the name of the series). The other is this wonderful (and rarely seen in the medical literature) discussion of self-image and blame:

Although some patients may blame themselves and feel they caused their own illness, patients may also feel guilt about the toll that the illness takes on their family and caregivers. Eating is a major social, cultural, and religious ritual in society, and patients with head and neck cancer often cannot participate in this activity. Even going out to dinner can become an impossible task, and patients may often be concerned about the impact this has on their family. Likewise, facial disfigurement—even if only temporary—may make it emotionally difficult for patients to leave the house, which can change the dynamic between patients and their loved ones. Feelings of guilt and self-blame in patients with head and neck cancer are therefore not only related to their own role in their illness but also to the belief that they are to blame for the impact the illness has on the quality of life of their loved ones. Physicians can assist patients with these feelings by encouraging them to talk about them with their loved ones, and even facilitating these conversations. For example, if a patient is accompanied to an office visit with a caregiver, the clinician can ask both of them, "What role has the illness taken on your relationship?" or even more directly, "Are you finding it difficult to eat out in public? How are you handling the changes imposed by the cancer on your social life or religious practices?"

The same issue also has a 'coda' for a previous perspectives piece about nausea and vomiting from last year.

And on the general cancer front JAMA also recently published the results of a randomized, controlled non-blinded trial comparing chemoembolization with radiofrequency ablation with both in patients with hepatocellular carcinoma. The study involved ~290 patients with unresectable (but not metastatic) hepatocellular carcinoma, at least one lesion greater than 3cm (as well as certain other tumor-specific entry criteria) & they were randomized to one of the 3 arms. I'm mentioning the trial for a couple reasons. First, there aren't too many therapies out there which have been shown to significantly improve survival in these patients and second, the study provides some general prognostic information for outcomes in this population: median survival was 24 months in the chemoembolization group, 22 months in the RFA group, and 37 months in the combined treatment group; 1, 3, and 5 year survivals were 75%, 32%, 13% in the chemoembolization group (very similar to the RFA group) and 83%, 55%, and 31% in the combined therapy group.

I'm curious how many other palliative clinicians are seeing these patients - my group sees a good number of them (usually referred by interventional radiology) as they near the end of their treatment course (or earlier if they're having a lot of symptoms) - and some relatively solid prognostic data are helpful.

2)
Archives of Internal Medicine has a research letter furthering the Vitamin D For Everything consensus that seems to be gathering in the last several years (falls, frailty/muscle weakness, cancer prevention, cancer therapy, and chronic generalized pain are just a few topics off the top of my head that vitamin D has been shown/purported to impact). This is about vitamin D for neuropathic pain; the letter presents uncontrolled observational data from giving 50 patients with painful diabetic neuropathies (and low serum D levels) ~2000 IU of vitamin D for a few months. The pain got quite a bit better. This is swell, and hypothesis generating to be sure - clearly controlled research is needed.

3)
Two from Journal of the American Geriatrics Society:

First is one looking at 6 month mortality after hospitalization for a COPD exacerbation. This was a single institution (Italian) prospective cohort study of ~240 elderly inpatients (mean age 82 years) with COPD exacerabations who were followed for 6 month mortality. For some reason patients with a previous history of 'chronic hypoxia' were excluded (???). Of note, the study cohort had 'nonacidemic' exacerbations which they defined as an arterial blood pH of greater than 7.34 (they don't clarify if they also excluded chronically hypercapneic patients who had high pCO2 but weren't actually acidemic). 2% died during the hospitalization (seems a touch low to me, given the age of the cohort) and 20% died by 6 months. They found a lot of the usual suspects were associated with a higher chance of death at 6 months (low BMI, poorer performance status, greater severity of COPD exacerbation) in univariate analysis. (None of the data were robust enough or presented in a way to affect clinical decision making, however.)

The one particularly interesting finding was that the functional status (measured via the Barthel Index) at the time of discharge (not at baseline) was predictive of 6 month mortality in the multivariate analysis - the authors comment on this too as it suggests (maybe) that the 'functional hit' one takes during the exacerbation is of particular prognostic importance. This makes sense but it's the first time I've seen it show up and I hope the authors/others look into this.

The other one is really for the prognosis completists out there: it looks at long term survival and functional outcomes for elderly patients who have already survived 1 year after 'planned or unplanned surgery or medical intensive care unit treatment.' Why one would want to study this exact population (both unplanned surgery or MICU stay? already survived one year?) remains unclear to me. Most people were doing fine, but of course they were since they'd already lived a year....

4)
Journal of Trauma has a paper looking at outcomes in elderly patients who suffer cervical spine fractures. This is a retrospective review of a single trauma center's experience with these patients. I have encountered only a very few elderly patients with cervical spine fractures (at least high C-spine ones) who have done well so this paper caught my eye. Acute mortality was ~25%, higher for high C-spine injuries and for those presenting with neurologic deficits (40-50% range). They also looked at the role of having an advance directive (they don't specify at all what they meant by this - POA forms, living wills, treatment limitations or not, etc.) and found that overall hospital length of stay was about 6 days shorter for these patients (despite having worse injury severity scores). They speculate that it may be because these patients' care goals were more palliative focused and so didn't linger in the hospital too long (although their ICU length of stays were identical to patients without ADs). Perhaps, but having an advance directive may also be a marker of increased family/social support, or preexisting nursing home residence, or other factors which could shorten a hospital stay....

5)
Resuscitation has a letter about the (what sounds like informal) development in one Canadian institution of "Do not MET" orders (MET being medical emergency team which sounds like what are frequently called rapid response teams in the US - essentially teams called in to rapidly assess/stabilize/transfer 'crashing' hospitalized patients prior to the patient needing a full 'code' called). It sounds like the MET team is still called even if a patient has a DNR order and so for appropriate patients people at their institution are writing, essentially, 'Do Not MET' orders as well.

If you found the 'METuscitate' in the title unbearable I'll point out that it's from the title of the the letter and I didn't make it up. It got me thinking, however, what does one actually call such a word? Is it a portmanteau? If so, how does one account for the acronym?

How to Submit A Presentation for a Medical Conference

Submitting a presentation to a medical conference can be a daunting task. It can be so intimidating many qualified people feel they should not even bother, because who are they to 'act' as experts in the field. Or one may have been rejected in the past and figured the odds are against you, so don't bother making an effort again. Others just enjoy going to the conference and not having to 'work.'

Well, I want to encourage you to submit a talk. If more people submit talks, an increased variety of talks can be selected. If more people submit talks, new viewpoints can be heard. If more people submit talks, new leaders can emerge. If more people submit talks, more professionals gain the confidence of speaking on international, national and regional stages.

So what is the best way to submit a presentation? Here are some tips I have gathered from submitting many talks to national and regional conferences, speaking and attending those conferences, and being on the committees to select from all the submissions. None of these tips are guaranteed to get your submission selected, but they may increase your chances.

What Topic to Choose?

Start Early
The time to start contemplating the talk you plan to submit, is actually at the conference you are attending. If you are planning on going next year, look at all the titles and see what areas are not covered well in breadth or depth, and see what areas have way too many offerings. This will help you gauge what area/topic may receive increased consideration from next year's committee. Be creative and think outside the box. What topics are important but often overlooked? That is how I have come to love prognostication; rarely taught, often misunderstood, used daily in medicine.

Start with Something Familiar
It is always easiest to start with something you know well, so you can at least decrease the amount of background work you must do. And if you have a lot of experience in that area, you can likely perform/improv better at your presentation as you can pull from a vast knowledge base. The corollary is...

Start with Something You Want to Understand More
Giving a presentation should not just be regurgitating facts and stories you know too well. Stretch your horizons and use this opportunity of an external deadline to learn more about some new area. That area should pique your curiosity, so you will be engaged with the material, otherwise the talk risks coming off very flat. And hopefully you have some experience with the topic, even if tangential. I can read all about llama farming in the hills of Peru, but since I am at least 3 degrees of separation from that topic, I probably would not give a sincere presentation (at least not without a lot more work).

Pick an Under-served Category
Many times conferences will post categories for desired talks. Look for the category you don't think will be popular. Chances are the committee will not have a lot of selections to choose from and your talk may be picked.

Don't Be Afraid of Bread and Butter
Being unique can get your talk selected, but often times at medical conferences there is a need for some of the basics. If you notice a topic has not been covered in the last two years of the conference, throw it out there. You can email the conference coordinators to get the last few years of programs, and then sort through what has been presented. If you are trying hard to get your talk selected, stay away from the topic that has been given yearly by the same person. Not likely to change, but sometimes change is good.

How Many Talks to Submit?
Honestly, it depends on your goal for presenting at the conference. If you really want to speak about the one thing you are passionate about, just submit one talk. If you want to get more national/regional/local exposure, submit three and hope two will get chosen. If you ever have three or more talks at a conference, you will not enjoy the conference. You will miss out on many opportunities because you will be planning your talk. So if you get all your talks selected, do not be afraid to tell the committee you would like to decrease the number of talks you will present. They may be sad, but I doubt they will seek retribution.

Submitting Your Talk

The Title
The title shouldn't be that important. It is just a few words. My talk is 60 minutes, but my title can be said in 6 seconds. Big deal. But the title is very important! This is your calling card to the selection committee and to the attendees. Think of it like a newspaper headline. In 8 words or less do you want to know more about something. And do try to use less than 8-10 words, because a title that is too long tells your audience you may not have good editing skills and your talk is bound to go too long, and have too many slides that you don't have time to get to.

Choose your words wisely and your title can shine. Pick bland but descriptive; your chances are so-so. Pick flashy but confusing; good luck. Pick creative and informative; bingo. Stay away from cliches and puns. Sinclair's Maxim: There will always be at least one presentation using 'the good, the bad and the ugly.' Alliteration is good but don't go overboard. The colon (punctuation, not the anatomy) seems to be very popular these days. It allows for something punchy and catchy on on side of the colon and something serious on the other side. Kind of like a grammatical mullet: business in the front, party in the back.

A good title gives some information, but is slightly provocative poking the learner to want to know what you are up to. That way they come to your talk. 'Evidence-based' is a buzz word, but it may start to be overused for when the speaker wants you to know, "Hey, I looked some of this stuff up." (Yes, I am guilty of using EB in my titles.)

The Speakers
Should you present alone or with others? Speaking with other people sounds like a great idea in the planning stages. 'Sara will take this part, and Dave will finish the talk, and I will cover the medicines. ' But in reality the coordination makes collaboration on presentations should cause hesitation. For a multi-presenter talk to go well, you should plan on a lot more time for ensuring the multiple presenters actually enhance one another and not turn into the Keystone Cops. Having speakers from different disciplines or different regions can help in raising the level of credibility for a talk, but that should not be the only reason to collaborate.

The Abstract
Follow the rules.

The Abstract (part two)
Did you read the section above? I mean it. Word count rules, figure rules, title format rules. Look them over again and again. And hand check the spelling after your computer does it for you. Eye now these form personnel experience. Please hand check your spelling!

Understand if the abstract is what is going to be printed in the brochures and other printed materials for the conference. Are you writing for the selection committee or for the selection committee and the learners? If #1, you can add in some commentary, if #2, it is more marketing than explanation. Don't waste your word count on what other people know about the subject by endlessly quoting others or adding references. If you can't fill up more than 80% of the word count with your original thoughts, why should they give you 60 minutes to talk?

The Deadline
Finish it early. This way you can have others look it over before the real deadline and give you critical feedback.

If there are any other lessons I missed or parts you disagree with, please feel free to leave them in the comments section.

"I Wanna Be A DNR" and other Goodness from the Web

Since it is Friday, let's have a little fun. Here are some palliative care related links and highlights from the web.

A ICU Nurse and some colleagues rewrote the lyrics to the popular Nickelback song "Rockstar" to emphasize how some patients may feel in the ICU. The video itself is just the lyrics. Here is hoping she puts together more song parodies and maybe a video or two. (Hat Tip: KPW)

If you cannot see the You Tube video, then click on the post title to hear the song on the original post.


If you go to the original You Tube page, make sure to read the comments for insight on how some medical professionals feel about this song and subject.

BMJ has selected palliative care as a focus for "Making a Difference" project. This project will focus on higlighting palliative care in BMJ Journals for the next year. Hooray, more to blog about! Thanks to all that voted. (HT: JP Pinzon)

Dr. Wes comments on the general unhelpful nature of point and click electronic medical records systems for nursing notes. I don't think this is limited to just nurses, as I have seen some doctor's notes look the same regardless of the patient. Why must EMR's have so much data that is worthless? Many of the EMR's I have seen are good for data in, but not for data out. Anybody have a solution? (Thx: Kevin MD)

Psychology Today rails against the 'stages of grief' model being misconstrued again and again as a road map for how you are supposed to grieve. The article has some good points, but without some structure for beginning to tease apart such a complex phenomena and without a basic roadmap, it is that much more difficult to identify complicated grief, and figure out how best to support those experiencing it. A real Catch-22. (Thx: HFA Blog)

Also check out HFA's blog for locally oriented coverage of the Dartmouth Atlas Study. Great post!

Hospice Guy is starting to post more...Hooray! And this time he bares his soul about the Hospice Cap. Don't know about the hospice cap. Well Pallimed has not really commented on it yet, but may soon.

The anonymous Angry Pharmacist has a few choice (not safe for work (NSFW) or sensitive ears) words about the DEA and controlled substance regulation between his pharmacy and his wholesaler. Some interesting points I did not know about pharmacies hidden in the ranting.

Dan Savage, the outspoken sex-advice columnist, eulogized his mother in his column. A profound look at emotions and grief and how one single curse word can convey so much.

At the Hospice and Nursing Homes Blog, Frances Shani Parker has a great poem about the "loss" of our senses and abilities Here is a tiny excerpt:

Handfuls of August clouds
whisk you to a picnic,
hint at mashed potatoes.

Have a good weekend all! I will be off-blog for two weeks in Australia (to give a talk on the clinician's estimate of survival and meet with my CPC mentor).

I have dutifully prepared a few posts ahead of time for Drew to post for me so I don't appear to be a slacker. I am excited to leave, but also excited to come back because Pallimed has some big surprises coming up in mid-May! Any guesses?
Photo courtesy of flick.com user Vermin Inc

Crying Doctors? How to Be A Good Palliative Care Doctor