Sunday, September 26, 2010
|A Perfect Morning at Glacier National Park|
Photo by Flickr user: Trey Ratcliff
This inaugural post in a new Pallimed series on health policy for palliative care groupies has taken longer to write than I expected. Why? I expected to start in the clichéd manner: by defining the term “health policy.” But I was stopped short when I could not find a definition for health policy. The websites, textbooks and articles that I consulted all take for granted that we know health policy when we see it. Many sources discuss topics covered under health policy (such as access, quality, financing, delivery systems, workforce), but none that I could find offered what I considered a useful, concise definition that set clear boundaries for the field.
Since it is impossible to prove the negative, and feeling very uncertain about the thoroughness of my research (maybe I had just missed some great definition out there that EVERYBODY but me knows about), I consulted with Dr. Gerard Anderson, my professor from doctoral student days in health policy and management at Johns Hopkins School of Public Health. Gerry confirmed in an email, “there is no uniformly agreed upon definition.” There you have it. So I am left to my own devices in trying to paint for you readers the major concerns, techniques, and boundaries of the field of health policy.
So what is health policy? For me, a key defining aspect of health policy is that it takes a 30,000 foot view of the health of a population and of the systemic factors (political systems, health financing, cultural norms) that contribute or detract from a population’s health. Contrast this to the clinical view, which put the needs and concerns of a particular individual (and possibly that individual’s family) first and foremost.
Photo by Flick user Bruno C
Sunday, September 26, 2010 by Dale Lupu, PhD ·
I am a realist about this. The political aspect of policy-making proceeds at its own pace, usually without slowing to wait for the results from years-long and careful demonstrations. (Does anyone REALLY know at this point whether medical homes or accountable care organizations work? They are in the health reform legislation anyway.)
by Dale Lupu, PhD ·
I thought I would post on what I hope will turn out to be an occasional series on sexuality here on Pallimed. We've covered sexuality some before. A post that leaps to mind is one by Christian in 2007 about the controversy that arose over a case where the staff at the world's first hospice designed specifically for young adults openly deliberated and decided to facilitate a 22-year-old patient's request to have sex before he died.
by Brian McMichael, M.D. ·
Tuesday, September 21, 2010
On to the best of the medical blogosphere! No themes here but I did ask (like GruntDoc) to include a post of other than your submission to help broaden our reach this week.
One of my new favorite blogs to read is The Neurocritic, who I stumbled upon with the recent review of the NEJM Pallaitive Care article and how it can help debunk 'death panel' myths. Read to the very end for why this post is so important to The Neurocritic.
Tony Chen shares a post by Nick Jacobs from the very new American Board of Integrative Holistic Medicine blog "When Healing and Science Converge." This blog has only been around for a couple of months, let's hope they stick with it.
MD from A Medical Resident's Journey writes about the recent WSJ piece on White Coat Ceremonies. Is empathy teachable? And bonus sharing with a post from Dr. Wes (@doctorwes) on the same topic, "On Humanizing Medicine."
Doctor Fizzy submits a post from next week's host Dr. Grumpy on the idiocy of e-prescribing. And probably the best new blog I have seen in recent months Doctor Fizzy's own 'A Cartoon Guide to Becoming a Doctor.' I really did enjoy the cartoon descriptions of a headache.
Dr. Rich (@DrRich1) at The Covert Rationing Blog discussed the upcoming Guideline Wars with health reform with the cleverly titled but imaginary SYNTAX trial. Dr Rich also kindly introduced me to The Road to Hellth (by Dr. Perednia) with a post about when a doctor tells his patient how the medical system looks from a doctor's point of view.
Jill of All Trades shares three great blogs that should get more attention, while submitting none of her own. She would be popular in my kids pre-school class with sharing skills like that! Here they are:
- Dr. Synonmous, a family practice doc, no relation to Dr. Anonymous that I can tell.
- Lockupdoc, (@lockupdoc) a psychiatrist in corrections
- And this was her blog post of note from WhiteCoat's Callroom: What's Fair? about writing prescriptions for OTC medicines in the ED.
Apparently Somatosphere (@Somatosphere) and blogger Kalman Applbaum are not afraid of Big Bad Pharma or the backlash from 'complicit doctors' as he reviews the book "White Coat, Black Hat Adventures on the Dark Side of Medicine."
Ken Covinsky writes at GeriPal about Humility in medicne, something that should be talked about more often. By the way GeriPal (@GeriPalBlog) is an excellent team geriatrics/palliative care blog if you have not seen it already.
Maria Gifford at Better Health interviews Thomas Goetz about his recent book on personalized medicine and more importantly how to make good medical decisions. Maria also wanted to share a guest blog post from Gary Schwitzer's blog Health News Review about the future of breast and ovarian cancer guidance for women with BRCA mutations.
Elaine Schattner blogs at Medical Lessons (@MedicalLessons) a classic post about how checklists (a la Gawande) may change the culture of medicine. If you ever wondered if you needed more 'poka-yoke' read this post. Elaine also submitted a blog post from MD Whistleblower (@MDWhistleblower) (aka Dr. Michael Kirsch - he outed himself, I didn't blow any whistles!), titled Evidence-Based Medicine in Disguise: Beware the Surrogate because 'with so much emphasis and real need for greater EBM (evidence-based medicine), we should be aware of its limitations.'
John Schumann at the blog Glass Hospital (such creative names we bloggers have!) gives us a great glimpse into the skill of listening with this post Doctor Yenta. An excerpt:
As an internist, I’m trained to do things:
I listen. I ask.
I examine, order, and test.
And then I assess.
I certainly try to treat. All too often, this includesprescribing.
What frequently gets lost in this paradigm is that on many occasions, the listening part is often enough.
Laika (aka @laikas) shows how other blogs can inspire you to write. After seeing Musings of a Dinosaur and db's Medical Rants talk about why orthostatic vital signs should not always be considered scut work. This reminded Laika of a story about PCR and chromosome analysis. Funny how our brains work sometimes!
Thanks so much for reading this week and thanks again to Nick Genes for organizing Grand Rounds. Check out next week's host Dr. Grumpy and submit your posts early.
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Tuesday, September 21, 2010 by Christian Sinclair ·
Wednesday, September 15, 2010
I've been toying around with an idea for a lighter post the last few months, particularly with the new fresh fellow season which is upon us, and thought our 1000th post was a good opportunity to do this. I've been thinking about this lately with the new fellows, because I've been finding myself saying these things over and over, as I do every year, as I talk with trainees about this wonderful thing we do called palliative care.
So here they are - pearls for successful palliative care consultation (in no particular order). I make no claims that any of these are original to me even if I've lost track of where they came from. Feel free to claim them for yourself in the comments. Few of these, particularly the ones I came up with, are aphoristic - if any of you can aphorize them please do so, in the comments. If we get some good additions we may try to find a more permanent home to our collected wisdom.
- Assume nothing, ever.
- Always talk to the team first.
- Respond to emotion with emotion.
- 75% of what we do is showing up and shutting up.
- Tame the beast inside who just wants to talk, talk, talk.
- Don't just do something, stand there.
- Acute symptoms = acute meds. (That is - don't jack around with long-acting/continuous meds for out of control symptoms without first actually making someone comfortable with bolus/immediate-acting meds.) This is a variation of the idea behind:
- NO DRIPS 'TITRATED FOR COMFORT.'
- 'Good work' describes a process, not an outcome.
- Palliative care is just good medicine.
- And what is their bowel regimen?
- What is their narrative?
- Just because someone has less than 6 months to live doesn't mean hospice is right for them.
- You should worry more about your patients who want to die, and less about those who are desperate to live.
- It's not about you. (This is in reference to patients' and families' emotions.)
16. You can't shine shit.
Please add your own.
Thanks for reading, thanks for sharing Pallimed with your friends and colleagues, and thanks for commenting.
(Image from here, via Google image search. Could not identify any copyright information.)
Wednesday, September 15, 2010 by Drew Rosielle MD ·
On the eve of our 1,000th post (this is #999) Pallimed is very excited to be hosting Grand Rounds for the fourth time (find previous editions here: 2007, 2008, 2009). There will be no particular theme assigned this week, but I will be adding a little wrinkle to the submission process: If you submit one of your own blog posts you also have to submit a recent blog post from another blogger. Help me find the BEST in medical blogs out there!
I will be looking around myself and finding a few selections of my own as well. Email your submissions to email@example.com with "Grand Rounds" in the subject header. Deadline for submissions will be 5pm CT on Sunday September 19th. Please be sure to include why you think your submissions should be included in the BEST of the blogosphere. You could also tweet me any of your links this week to @ctsinclair with the tag #gr Fair warning: Not all submissions will be included in the final post. I will be looking at your other blog posts too and if I find something better on your blog I might choose that one instead.
by Christian Sinclair ·
Monday, September 13, 2010
Annals of Internal Medicine recently had a timely discussion of advance care planning, trying to focus the discussion away from helping patients specify what what they'd want, and more towards laying the groundwork for appropriate decision making by loved ones whenever that time comes. Good one for the teaching file.
That is, instead of thinking of ACP as patients pre-specifying 'If X happens, then I want Y,' thinking about it more as helping patients and their loved ones prepare for the decisions they'll be faced when the time comes - e.g. helping them think about 'EOL' decision-making, about what are acceptable outcomes of therapy, etc. My own drastic condensation of what they propose is focusing the planning on outcomes as opposed to specific individual therapies. E.g. less 'No feeding tubes' and more helping prepare loved ones to think about the medical decisions they may be faced with in light of what an acceptable outcome, 'quality of life' would be, etc.
Monday, September 13, 2010 by Drew Rosielle MD ·
The 'palliative care extends life in NSCLCA trial' has made its way to broadcast nightly news (see embed below). It's an interesting couple minutes, and while very positive about palliative care, I'm curious as to others' reactions to this. Watch it - you'll see what I mean. The patient, a middle-aged man with advanced lung cancer who is clearly living with his cancer with as much dignity and vitality as could be imagined, is also the healthiest appearing advanced lung cancer patient I've seen in a while; much of the stock footage seems to take place on a pulmonary rehab unit (e.g. on the treadmill) (?); the palliative care clinician is called a 'guide'; and alternative medicine interventions are given as much airtime as anything else. It sorta de-medicalizes what we do, and if I had no clue what palliative care was I'd think it was some sort of friendly person who stuck you on a treadmill and referred you for qigong. It's kind of like watching one of those Zyprexa ads where you see that attractive middle-aged woman leading this meaning-filled, poignant life full of family and work and you say to yourself 'Gee I wish I felt like that & I don't even have bipolar disorder.' Such are the growing pains of fame for our field, I guess.
That aside - the piece focuses as much, or more, on quality of life and symptom improvement than the mortality benefit, and, per my post about the paper, I can't see how this is anything but a net boon to our patients and access to us.
Our blog contributor Brian McMichael alerted us to this - thanks Brian!
(Late edit - read Brian's comments for links to related interviews.)
by Drew Rosielle MD ·
Tuesday, September 7, 2010
|Drawing of a nasal cannula from Wikimedia Commons|
Hypoxia isn't always the cause of dyspnea, however, and Abernethy et al. set out to test the hypothesis that room air delivered by a concentrator at 2 liters per minute might rival the efficacy of oxygen delivered at the same rate for patients with advanced disease, refractory dyspnea, and normal blood oxygen concentrations (Pa02 >55 mmHg). The results of the double-blind, randomized control trial were published in Lancet recently.
Tuesday, September 7, 2010 by Lyle Fettig, MD ·
In case you were missing the latest edition of the best writing in the Hospice and Palliative Care blogosphere, you can hop on over to the AAHPM blog and find a smorgasbord of links to keep your brain satiated until the Fall TV premieres begin. I know Drew can't wait for Glee to start. (That is not true I just made that up. Or maybe it is true. I doubt it. End internal conversation.)
Check it out and go give some comment love to all the writers out there giving their all. Don't forget to spread the good stuff to your IDT, as well as on Facebook, Twitter or LinkedIn if you find something you really enjoyed.
And if you get to the end and click on the Geripal link, I guarantee you will laugh and anyone who doesn't live and breathe palliation and communication will not get the joke. Everyone loves an inside joke; unless they don't get it.
Cartoon by Dave Walker. Find more cartoons you can freely re-use on your blog at We Blog Cartoons.
by Christian Sinclair ·
(Note for our email subscribers you may want to go to the actual post to see all the embedded media best.)
For those of you who missed the announcement back in July, hospice and palliative medicine has enough people on Twitter that we started having a weekly Tweetchat every Wednesday night at 9p ET/6p PT. We have had good turnout and support from a lot of people who think what we do is very important. If you that last sentence confused you just watch this for a quick tutorial (over 1200 views on Slideshare so far):
by Christian Sinclair ·