Friday, February 16, 2018

2018 12th Annual Pallimed-GeriPal Party

by Christian Sinclair (@ctsinclair)


Every February the questions start rolling in, "When is the Pallimed-GeriPal party?" Just so you know and can mark it on your calendars from here to eternity, it has a standing reserved spot on Thursday night at 9pm local time the week of the Annual Assembly of Hospice and Palliative Care (but just to be clear it is not an official part of the meeting). And as always, feel free to invite and bring any colleagues or new friends with you as this is not an exclusive crowd.

So for 2018, that means you should clear off the evening of March 15th. We will, of course, be doing our traditional pub crawl starting at Sonsie at 9pm. Around 10pm we will likely be moving on to the next destination. Like always though, these are rough estimates of time, so if you want to know the details, follow the hashtag #HPMparty on Twitter. You can also find information and people talking before, during and after the event on the Facebook Event page.

And new this year, we are adding an event! Get ready for the first ever #HPMparty Escape Room! We are partnering with Escape the Room Boston to reserve three different themed rooms over five time slots from 7:20 to 9:40. (We can open up a later one if the demand is high!) You can always join up with the pub crawl before or after (or not at all, if that is not your thing!). No need to buy anything or sign up for anything if you are just doing the pub crawl.

ESCAPE ROOM DETAILS: Each room holds 8-12 guests where you will work together solving puzzles and clues with excellent communication skills (honed as excellent hospice and palliative care clinicians of course). It will cost $30 per person and we only have around 60 slots, so sign up soon! All of the Escape Rooms are reserved exclusively for us, so you will be working with fellow clinicians and not somebody on their first date...awkward! You will want to get to the Escape room 15 minutes ahead of your scheduled time and it takes 15 minutes by car and 20 minutes by train. Be on time! Once your room starts you will be there no longer than 70 minutes (60 to finish the room and 10 to wrap up). If you are good you’ll be done early!

Example: Reserve the 9:00pm time slot. Leave for Escape the Room Boston at 830 to get there by 845. Do the Escape room at 9p and be done at 10p, take pics and leave!


Ways to follow the party from near or far:
#HPMparty twitter feed
#HPMparty Facebook Event Page

And if you are not already doing it - Follow Pallimed on Facebook, Twitter and Instagram and Follow GeriPal on Facebook, Twitter and your favorite podcasting app.


Friday, February 16, 2018 by Christian Sinclair ·

Wednesday, February 14, 2018

Did You Have To Say “Yet”?

by Ryan Nottingham and Gregg VandeKieft (@vandekieftg)

A middle-aged man* came to our ambulatory palliative care clinic with his family. With the exception of his recently diagnosed brain tumor, he was in peak physical condition. His diagnosis weighed heavily on his family and his personality changes and angry outbursts left them frayed. He did not feel the same burden as his family since these outbursts came to him in the form of blackouts. We could visualize him as a man of few words before his diagnosis, someone who would speak up with a dry one-liner. During this visit, his humor was touched with acidity. As we began our conversation, his pent up frustration slowly infused into the room. His wife was able to put her concerns on the table while his children held his hands. He visually softened and received their words without response. After the catharsis, when all questions had been asked and tears had been shed, the family looked exhausted but ready to move forward. Before the visit concluded, the physician completed a brief physical assessment. As he worked his way through the neurological exam, he noted positively to the patient, “no loss of strength yet”.

The patient looked up at him and with a thick voice asked, “Why did you have to say ‘yet’?” The pause was palpable. Visibly chastened, the physician responded, “You’re right. I apologize. That wasn’t very sensitive.”

Providing seriously ill patients with an honest idea of their disease while also helping them maintain a sense of normalcy in their life can be a delicate balance. Our language is laced with subtle reminders of prognosis. They do not have a disease, it is a progressive disease. Suddenly, CPR moves from being a standard measure to a heroic measure. Even if the phrases do not attest to lifespan, there are also reminders of their perpetual patient status. Our clinic recently went through a name change, from outpatient to ambulatory to avoid this exact issue. And the implications of the single word “yet” conveyed a message clearly heard by the patient that this seasoned palliative care physician, highly regarded for his communication skills, had in no way intended: “Your tumor hasn’t robbed of your strength yet, but it will!”

As much as we use our words to care for our patients, they also have the potential to cause harm. Many medication side effects are frustratingly vague and similar to potential disease symptoms; fatigue, headache, moodiness, and nausea, for example. While counseling patients to be aware of these effects, we can inadvertently trigger them to be hyperaware of their body processes. This information can subsequently lead to new or exacerbated symptoms that might not have been an issue otherwise. Allocating the appropriate amount of emphasis on various counseling points can ensure the patient is both well informed and at reduced risk of false-positive side effects.

For our patient, the amnestic qualities of his outbursts and his physical strength buffered him from his diagnosis. Even after our discussion, after his family had pulled out all the skeletons, he remained behind in the closet. In the article What It’s Like to Learn You’re Going to Die, the term “existential slap” denotes the moment when a dying person viscerally comprehends their upcoming demise. For some it comes at the time of diagnosis, others as their body begins to reflect symptoms of disease. For our gentleman, it would be several visits before his full realization of his clinical situation. So hearing the implicit message of his impending decline – of which he was cognitively aware but not yet emotionally prepared - was unwelcome. The tenor of the entire encounter was adversely affected by one unconsciously uttered word.

The balance between honesty and tact varies depending on the person, where they are in their illness trajectory, and the extent to which they have “processed” both the past and future course of their illness. Striking the right balance requires insight into the patient’s understanding of their illness and how they would like information to be presented. Palliative care opens conversations in which many people do not wish or expect to find themselves. Skillfully and sensitively dispensing the correct blend of hope and facts takes training, and occasionally trial and error. Sometimes, the only way to find out is to have a misstep – perhaps a misstep of a single word. Just remember: Slips happen. Some will be embarrassing; others inimical; some would even make Freud smile. These situations happen to everyone, in every discipline, at every experience level. So whether it is a misstep, misspeak, or mistake, remember to get back up and keep going. Your future patients will be grateful of how the experience helped you grow.

*Identifying details changed to protect patient privacy - Ed.

Ryan P. Nottingham, PharmD is a clinical pharmacist in Randallstown, MD. A recent transplant from Washington State, she enjoys exploring her new home with her husband and puppy and adding Old Bay to everything! Gregg VandeKieft, MD, MA is Medical Director for Palliative Care for Providence St. Joseph Health, Southwest Washington Region, and Associate Medical Director for the Providence Institute for Human Caring, Torrance, CA. He sometimes says things he wishes he could take back. You can find Gregg on Twitter at @vandekieftg

For more posts on communication, click here.

1. Barsky AJ. The Iatrogenic Potential of the Physician’s Words. JAMA. Published online October 31, 2017. doi:10.1001/jama.2017.16216
2. Dear J. What It’s Like to Know You’re Going to Die. The Atlantic. Published online November 2, 2017.

Wednesday, February 14, 2018 by Pallimed Editor ·

Sunday, February 4, 2018

Proposed Medicare Changes to Limit Opioid Prescribing

by Chad Kollas

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) published its Advance Notice of Methodological Changes for Calendar Year 2019. Included in these proposed rules were several directives intended to reduce "Opioid Overutilization” (see p. 202), including formal adoption of the “90 morphine milligram equivalent (MME) threshold cited in the CDC Guideline, which was developed by experts as the level that prescribers should generally avoid reaching with their patients (p. 203).” CMS proposed “adding additional flags for high-risk beneficiaries who use ‘potentiator’ drugs (such as gabapentin and pregabalin) in combination with prescription opioids (see p. 204).” CMS also proposes a 7-day limit for initial fills of prescription opioids for the treatment of acute pain. The proposed CMS rules are unclear about exceptions for patients enrolled in hospice or with cancer pain, but there seems to be a mechanism in place for prescribers to apply for an exception for each individual patient (p. 209-210).

On learning of these proposed CMS rules via social media, many members of the hospice and palliative medicine (HPM) community expressed several profound concerns: Foremost, how would these changes impact our patients and their care? How will the rules affect our daily practice? And, for the HPM policy wonks, how did the 90 MME threshold make its way into proposed federal policy without evidence from the medical literature.

As one of the aforementioned HPM policy wonks, I’d like to address the last question first. The 90 MME threshold was born in 2012, as part of a non-solicited petition to the Food & Drug Administration (FDA) from a group of physicians who identified themselves as subject experts and referred to themselves as Physicians for Responsible Opioid Prescribing (PROP). Ultimately, after reviewing open comments from stakeholders, the FDA declined adoption of PROP’s 90 MME proposal.

Undeterred, PROP successfully sought to place the 90 MME provision in the CDC Guideline for Prescribing Opioids for Chronic Pain, leading to criticism of the CDC for a lack of transparency by the pain management community. Ultimately, the CDC did recognize that certain patient populations, including patients receiving hospice and/or palliative care, might legitimately require opioid doses exceeding the 90 MME limit. The current CMS proposed rules, however, do not offer an exemption to this limit for these patients; they would instead further codify an opioid dose limit that was largely created in an arbitrary fashion based on a self-selected group of physician “experts” with no accountability to the HPM community.

This observation likely concerns those of us who ask how – as HPM practitioners – the proposed CMS rules will affect our practice. Of much greater importance is how these proposed rules would affect our patients. Opioid stigma in the setting of “The Opioid Crisis” is already a major barrier to patients receiving hospice and/or palliative care that adversely impacts their access to medications needed to maintain their quality of life. For example, in a recent study of 250 patients receiving outpatient palliative care at a cancer center, 54% reported feeling stigmatized for their use of opioid analgesics and 73% reported difficulty filling opioid prescriptions (Kollas CD, Boyer-Kollas B. Assessing Opioid Stigma in Oncology Outpatients Receiving Palliative Care for Cancer-related Pain. Accepted to 2018 AAHPM Annual Assembly). The proposed CMS rules, in their current form, would add to patients’ perception of opioid stigma and, at best, will result in delays in receiving medications to manage their chronic pain. At worst, some would not receive the amount of medication needed to relieve their pain, severely impacting their quality of life or driving them to desperate measures, like seeking illegal drugs. Ironically, CMS new rules could unintentionally accelerate the emerging trend in opioid overdose deaths: deaths from illicit drugs, like heroin or illegal fentanyl (see CDC data here).

While this sounds catastrophically bad, there is a small silver lining within CMS’s announcement; there will be an open period for comments from stakeholders. CMS will review all comments submitted via its website, whether submitted by an individual patient or physician or from a patient advocacy group or medical organization. And, as evidenced by the FDA’s response to the 90 MME proposal from PROP, these comments can make shape policy in a way that protects our patients’ access to critically-needed pain medication. Social media can be a great tool to help build a successful coalition of HPM stakeholders, but time is short – comments must be submitted by Monday, March 5, 2018. To submit comments as an individual, go to www.regulations.gov and enter docket number “CMS-2017-0163” in the search field, then follow the instructions for “submitting a comment.”

Dr. Kollas has provided outpatient palliative care at Orlando Health UFHealth Cancer Center for over 17 years. He first wrote about his personal experiences with chronic illness and pain in a 1997 article in the “On Being a Patient” series in Annals of Internal Medicine. You can find him on Twitter at @ChadDKollas.

Editor's note - The graphic was updated to reflect 2019 changes not 2018 changes as was indicated in the original post. Also, the wording was changed from 'no exemptions' to 'possibly (but not guaranteed).'

Sunday, February 4, 2018 by Pallimed Editor ·

Saturday, February 3, 2018

An Impromptu Group Conversation With Women in Hospice and Palliative Medicine

Collectively written by Allison Jordan, Katie Harmoney, SarahScott Dietz, Jeanette Ross, Emily Hahn, Meredith MacMartin, Christian Sinclair, Rachel Thienprayoon

Waking up today February 3rd, I (Christian) saw a discussion on our Facebook private messages for the Pallimed page about what we should post for National Women Physician Day (which is held on February 3rd the birthday of Elizabeth Blackwell, the birthday of the first US woman physician.) Jeanette had found the 2016 Pallimed post written by Meredith MacMartin and we posted that, but then I thought it would be great to write some fresh content on this new celebration. So I jumped over to Twitter and reached out to a handful of female colleagues on a direct group message and asked my co-authors above:

My first thought was, “let’s use the reach of Pallimed and social media to amplify women’s voices on this commemorative day!” As soon as I sent the DM I realized, maybe this wasn’t the wonderful idea I initially thought.

Oh my gosh…
the horrible realization hit me…
I was asking women peers to do work…
on a weekend…
with no notice…
on a day focused on the challenges and accomplishments of being a woman in medicine…
challenges often from the results of a historical and current male-dominated workplace...
and I am a man.

Thankfully they didn’t point this out to me, but what followed was a really fantastic conversation that Katie noted: “We could publish this thread!” So we organized and streamlined some of the discussion would love to share some of our observations to broaden the conversation.

The Initial Ask

Sinclair: Sorry for the group DM, if some of you don't know each other. But I was wondering if any of you would be interested in writing a piece on National Women Physician Day for Pallimed. Meredith (@GraniteDoc) wrote one in 2016. We didn't have one in 2017, and this one just snuck up on me and I didn't think to get one drafted before this year's day. You can email me with a submission. Will get it published today or tomorrow if I get it today. And if you want to enjoy your weekend, not writing, that is perfectly acceptable! No pressure, honest.
Harmoney: I'd love to, but am actually volunteering at a cancer fundraiser.
Jordan: Is there a specific topic that you would like the writers to discuss? LOL otherwise I’ll just send you “being a woman in medicine is hard. We are still working in a system that was designed by men ages ago. Women need to be at the table to redesign the system so that it works for everyone.”
Dietz: May be able to, subject to the whim of a 16 day old. Right now I would probably rant in a sleep-deprived manner about parental leave. 😆 But yes, what Allison said, LOL.
Ross: Sarah, congratulations on the new baby! I was thinking something about women in #hpm but I don’t think I know all relevant info. Could go:
First hospice and palliative medicine (HPM) Physician: Dr. Cicely Saunders
First USA HPM Physician: Dr. Elizabeth Kubler-Ross?
Like first AAHPM woman president ....
Dietz: I would love to work on a post about women leadership in early HPM but I don't think it's going to come together this weekend. Next year's women's day?

On Mentors

Ross: Did you have a woman mentor play an important role in HPM for you. I would say that is why I’m grateful to mentors who help me think about how to balance life and work.
Jordan: Mentorship is HUGE.I could not have done this without male and female mentors
Dietz: I haven't had a female mentor. I can only imagine that would be a very helpful experience! Jordan: Sarah, I would strongly advocate for a mentor. And peer mentors too. Sometimes your girlfriends will be great cheerleaders to give you the courage to ask for what you need/want. I have different mentors for different reasons. I have a mentor for work/life balance. I have a mentor to help me with leadership skills, and I have a mentor to help connect me with people. I have the mentor for when I need a kick in the pants to push me to not settle.
Harmoney: Yeah. It's so important to pick mentors for each thing.
Jordan: LOL! I need a lot of help. It takes a village! But I can’t do this alone and there are women and men out there who have AMAZING knowledge.
Harmoney: My HPM mentor is a lady. She's very helpful and open about her own struggles. Helps that she’s late/mid-career.
Jordan: So the mentorship is great, but it still doesn’t fix systemic problems with the way our jobs are designed.
Harmoney: We need a fundamental culture change.
Jordan: I agree Katie. if we all work together and advocate for what we need, with the support of mentors, change can happen. We need people in leadership and positions of influence to help change the culture. Otherwise we will continue to have burnout, physician shortages, and people choosing to not go into HPM or medicine.
Harmoney: We have this in peds oncology too. So much pressure, jobs are super competitive, funding is scarce.

The Future of Medicine

Dietz: Baby woke up, reading back. (She’s amazing. I have two boys but today I’m really reflecting on what I want medicine to look like, if she decides to be a doctor like her parents. I really want to not have to worry that it’ll be different for her than it would be for her brothers.)
Jordan: I worry about my goddaughters and they see me and their mom in medicine... I want it to be different for them. Right now they don’t understand what we do (they are 2 and 4) but they clearly get we are not like other women in their lives.
Harmoney: Medicine also has a culture of us doing everything: patient care, research, grants, writing. It’s unsustainable.
Jordan: “Medicine is a very jealous lover. It will take as much time as you give it.”
Dietz: There’s an enormous pressure to be perfect or super-human in Medicine, because of the part where we have people’s lives in our hands. It makes it really hard to admit there’s a problem. Any problem, from “my car wouldn’t start this morning” to “I am so depressed I can’t get out of bed.”
Harmoney: Gifted physicians are being forced to choose family versus career because it's a system not designed to accommodate both.
Dietz: True for both male and female! The system is damaging for both genders but it exists in part because the structure is built on one parent at home full time to enable crazy work hours and expectations.
Harmoney: Agreed.
Jordan: There is talent literally walking away from medicine because of poor design. I bet burnout would decrease and we could retain talent if we had a part in the design.
Thienprayoon: My husband had a job gave him 6 weeks paid paternity leave. which was AWESOME. he felt guilty for taking it, since no one else does, because that is the culture of the company. Looking to the future, leave is not something he'll likely get again, which impacts us and our whole family SO much.
Dietz: My husband had to spend 2 weeks of sick/regular leave for his "paternity" leave, since FMLA would have been unpaid and we can't afford that. His group worked with him but it shouldn’t be this complicated. It's ridiculous. There is such a backlash for physicians in general against taking time for family, things as simple as looking for positions that don't require call, or even that do have call but on a predictable schedule instead of random assignments. Pumping at work, heaven forbid. I’m grateful my current workplace is supportive but I know many who are not as lucky.

Let’s Publish This!

Ross: I like this thread Esther Choo (@choo_ek) has going showing all the disparities in medicine.
Harmoney: We could publish this thread.
Dietz: Christian didn't know what a bag of worms he was opening in his DM. 😆
Jordan: LOL Christian got awfully quiet…
Ross: Christian, the post could be about how you tried to get HPM women to write a post and you got an earful about why we couldn’t.
Dietz: LOL
Sinclair: I just went to make lunch for my kids and came back to all this! I learned a lot and see a lot of some of the issues Kelly and I face together and as individuals. I like Katie and Jeanette’s idea.

The Hard Work of Hospice and Palliative Medicine

Jordan: There needs to be more flexibility. This job and especially Palliative Medicine is HARD. You can’t expect me to see a high number of consults, make people sad all day, and then get upset when I want to not take call on weekends and nights.
Harmoney: But the issue is that we are hard on each other. We’re part of the problem.
Jordan: We have to speak up and say NO to some of the foolishness.
Harmoney: And also support one another. We've got to advocate for our colleagues, male or female. It's really the only way to fix this. I do think that medicine has worn down my resilience. People in medicine need to advocate for our health.
Jordan: We need to not suffer in silence. Women physicians and especially us doing HPM should not work alone. We need each other!
Dietz: We do!!
Harmoney: We need to hold each other up!
Jordan: I’m thankful that during my med/psych training they paid for us to go to therapy.
Harmoney: I think of therapy as a requirement in medicine.
Jordan: I worried about my non-psych colleagues. They didn’t get help and their department would NOT cover therapy. Therapy should be part of the redesign of medicine.
Okay. We need:
1: women at the table for leadership
2: women included in the redesign of medicine
3: mentorship
4: no stigma with seeking mental health services
5: health systems that support people with families or who just want to have a life outside of the hospital
6. Support for those in academics to advance their careers and STAY in medicine
Dietz: Recognition that men suffer under the current system as well. (Toxic masculinity, anyone?)
Jordan: YAS Sarah!
Dietz: Just a second, I have a mac and cheese situation.😆
Sinclair: Sounds delicious!
Hahn: I want mac and cheese.
Harmoney: Me too!
Dietz: 3 yo NEEDS mac and cheese y'all. It's dire.
Harmoney: It's a serious need.

Women Leadership in Hospice and Palliative Medicine

Ross: I wonder if there any stats about how women are represented in HPM, like how many are in leadership positions like regional hospice medical directors, division chief, etc?
Jordan: Good question. How is the Academy (AAHPM) doing? How is HPM doing?
Ross: My gist is that we may be better than other specialties. HPM being founded by a woman and I think a good group of women started AAHPM. For example, Chest (the pulmonary society) just now has a woman president-elect. That doesn’t mean we still have room to grow.
Sinclair: I count 15 men and 12 women as Presidents of AAHPM since founding in 1989.
Jordan: Plenty of room to grow. I think women would be more inclined to take leadership positions if they knew they would have adequate support at work AND at home.
Sinclair: I recall being surprised in 2008 or 2009 a session at the Annual Assembly of HPM focused on “Women and Leadership in HPM.” My career had essentially been working only with women physicians as colleagues and supervisors. I was wishing for more male physicians honestly. Only recently did I realize what the need for that session was. Currently, our HPM physician group is 3 men, 8 women led by a woman.
Ross: In my department, we are like 8 women to 2 men HPM specialists.
Harmoney: HPM seems much more balanced than oncology. HPM is a field where we have this discussion.
Jordan: True Katie. We actually have a better shot at changing the culture. Because we are new, we have a unique opportunity to negotiate and define our role as we become part of the fabric of healthcare. We might be a beacon of hope that can become a model for other outdated specialties.
Harmoney: I was floored during interviews because I was asked about self-care.
Jordan: The other specialties may look to HPM to figure out how to do self-care right. So we have to get it right and set the tone. And with a woman at the lead, it can happen. It could happen with a guy too, don’t get me wrong.
Harmoney: The right guy.

Future Collaboration

Ross: I see an AAHPM 2019 submission in our future.
Dietz: Love it!
Harmoney: As a group? I’m down. I'm interested to see what this looks like.
Jordan: It’s going to be epic
Hahn: Oh my just read through this whole thing! It really could just be published!

You can find all of the authors on Twitter: Allison Jordan (@doctorjordan) , Katie Harmoney, SarahScott Dietz (@SDiezMD), Jeanette Ross (@RossJeanette), Emily Hahn (@TexasKidDoc), Meredith MacMartin (@GraniteDoc), Christian Sinclair (@ctsinclair), Rachel Thienprayoon (@RThienprayoon). They often tweet about #hpm.

Saturday, February 3, 2018 by Christian Sinclair ·

Pallimed | Blogger Template adapted from Mash2 by Bloggermint