Friday, April 3, 2009
NPR's Fresh Air yesterday (April 2) had an extended interview with Dr. Robert Martensen about his book A Life Worth Living (interview here; you can stream this free online). The interview is very personal (about family members' deaths) and also talks candidly and wisely about the state of end-of-life care in the US. He also gives a pretty good description of what palliative care is and does and should do. One of his major points is the wholsesale abandonment of real communication with patients and families who are dying or chronically ill and declining about what's going on, what the real options are, etc. It's great. (Thanks to my wife for letting me know abou this.)
JCO has a great paper about teaching oncologists to teach communication skills to oncology fellows (free full-text here), which leads off with this compelling scenario:
Dr B, a faculty oncologist supervising fellows at an outpatient oncology clinic, faces a common teaching quandary. A second-year oncology fellow presents a patient with metastatic lung cancer, which has progressed despite second-line palliative chemotherapy. The fellow concludes his presentation, which was technically impeccable, by saying, "I thought the patient was not getting how bad this is, so it was time to hang crepe. I told him it was a choice between phase I or nothing." Dr B knows the fellow to be a careful physician who is genuinely concerned about the well-being of his patients. Yet the fellow's comment about hanging crepe raises a red flag for Dr B, because in his experience, blunt disclosures of poor prognoses may lead patients to wonder if their physician is still on their side. In addition, Dr B does not like telling patients that there is nothing more to be done. But he is not sure how to get the fellow to understand this. Should he confront the fellow about this, or just let the comment pass?This article summarizes the approach of the Oncotalk Teach program's faculty development training in teaching communication skills to fellows - particularly the specific model they propose using which involves (before patient communication encounters) establishing goals for the encounter - having fellows establish their own goals/learning needs - with the faculty acting more as a guide/mentor to the fellow as opposed to a role-model (in which the fellow watches and is supposed to learn what to do through observation) or critic/judge ('you should have done it this way').
It's a model which clearly has relevance for palliative care clinicians who train others in communication as well, and as I read it it was a good opportunity to reflect on my own strategies and how they could be improved. I hope to see more in the future about this.
BMJ is publishing a 4-part series about research about prognosis - first one is here. (It does not appear that the series is going to be particularly aimed at prognostication in patients with terminal illnesses, however it will hopefully be relevant for all of us who try to interpret prognosis literature frequently). This paper is a general discussion of prognostic research, and goes a little bit into the problems clinically interpreting complex prognostic models, particularly as they are initially developed, published, and we all sit around wondering Well what do we do with this? Hopefully the series will be a good, EBM-primer on prognostic research... A quote:
'Finally, clinicians often do not know how to use predicted probabilities in their decision making. Validation studies are scarce, but even fewer models are tested for their ability to change clinicians’ decisions, let alone to change patient outcome. We support the view that no prediction model should be implemented in practice until, at a minimum, its performance has been validated in new individuals. The third article in this series discusses why validation studies are important and how to design and interpret them.'4)
BMJ also recently published a news story on concerns that opening up funding in the UK for costly treatments for patients at the end of life will divert funding away from other patients/preventative care/etc. It involves recent efforts to increase access in the UK to expensive but potentially life prolonging treatments in patients with advanced illnessess. They quote the astonishing figure that 64% of an individual's lifetime health care costs occur in the last year of life in the UK. Astonishing, at least on the surface; however by definition one's last year of life is usually when one is the most ill and need the most health care.... I am curious as to whether we (in the US) will begin having this conversation as well given the talk of Medicare requiring that they will require more evidence that certain treatments work prior to paying for them.
(Thanks to Dr. Andy Billings for alerting me to this.)