Cancer Reporting in the Media - Guess what they report on?

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St. Patrick's day is good for celebrating your Irish heritage or fondness for food coloring, but it may have a new tradition, the release of major Palliative Care articles. Three major articles came out this week. Today JAMA published "Availability and Integration of Palliative Care at US Cancer Centers", yesterday the Archives of Internal Medicine released "Cancer and the Media: How Does the News Report on Treatment and Outcomes?" and on the 15th CMAJ released "Why do patients with cancer visit the emergency department near the end of life?"

So why the St. Patrick's day logjam of articles? Some may say it is mere coincidence, but I think there may be some meta-meaning here. By the power of Grayskull Wikipedia I found that St. Patrick is very likely two different people, one of which is named Palladius...very similar to 'palliative'...which is why I am sure the editors of these three journals got together to plan this bounty of articles. (I guess the New England Journal of Medicine missed the conference call). We will see if next year the same thing happens. Enough conspiracy talk...

This Archives of Internal Medicine study by Fischman, Have and Casarett shines a light on the bias present in the media towards the 'fight' against cancer. (other good blog posts on words used in cancer: Drew Rosielle on 'Hope' and GeriPal on 'fighting cancer')  The researchers looked at 8 newspapers (Chicago Sun-Times, Chicago Tribune, Daily-Herald Chicago, New York Daily, New York Post, New York Times, Philadelphia Daily News , Philadelphia Inquirer) and 5 magazines (Newsweek, Parade, People, Redbook, Time). (What no Washington Post or Cosmo?)

The main points in the articles that were coded if they were mentioned were:

• Survival
• Mortality
• Aggressive/curative
• Treatment failures
• Adverse events
• Palliative focus

The researchers found a very significant bias towards reporting cures/survivors (32%) over deaths (8%) and sadly only 2% that mentioned both. Also they found that adverse events and treatment failures were rarely reported (both less than 30%).

And of course the result you have been waiting for, 11 articles out of 436 (3%) mentioned aggressive and pallaitive measures and only 2 (two, dos, deux, zwei!) of the articles focused exclusively on end of life care exclusively. Well the researches only searched from 2005-7 and so they missed the whole past year of New York Times articles we have been writing about. Still it is shocking in 'cancer focused' articles only 0.5% mention end-of-life care exclusively?!

Pallimed was initially focused on EBM style analysis of palliative care articles, but we have expanded our scope to report on palliative care in the media also, and this study justifies the importance of getting the story about good palliative care into the main media news cycles. It is not just enough that there are articles about cancer treatments (mainly read by cancer patients and their families) or articles about hospice or palliative care programs (read by hospice and palliative care staff and families with hospice experience.) We need articles that combine the two so people are equally exposed to the balance of treatments that exist out there. Few patients or families facing cancer diagnoses will choose to read the 'hospice is valuable' headline when juxtaposed with a 'new cancer treatment' headline.

But it is important to understand the view of the journalist and editors as well. 'New cancer treatment' headlines may sell more copies than 'hospice is valuable' headlines. Also a new treatment being available is news because it is new, different, interesting. Having articles about how people have poor survival with a cancer diagnosis is not new, different or interesting. Palliative care and hospice organizations need to make sure the journalists and editors hear the great stories we see every day in our work. The human interest perspective is very powerful. Some hospices are better at connecting with the media than others. Maybe it was time we all had a lesson in how to best interact professionally with the media.

For reference I have uploaded a slidedeck I gave at the NHPCO conference in 2007 titled: Working With the Media: How to Reach the Widest Audience Possible. It is embedded below.

View more presentations from Christian Sinclair, MD.

If you know of any other good media resources for medical professionals please comment below.  Hospice Foundation of America also posted about this today.

Fishman, J., Ten Have, T., & Casarett, D. (2010). Cancer and the Media: How Does the News Report on Treatment and Outcomes? Archives of Internal Medicine, 170 (6), 515-518 DOI: 10.1001/archinternmed.2010.11

Palliative Care in Cancer Centers - Horses of many different colors

The third Palliative Care related article released for St. Patrick's (Palladius) day is a article that speaks to what many of us in the field know already:

Palliative Care is a chameleon: it looks different depending on the background of the institution.

But as the editor-in-chief of the Lancet has said: "It is not true, until it is published." Well JAMA has published a little bit of truth with the article: "Availability and Integration of Palliative Care at US Cancer Centers."  We have already known from CAPC data about a variability in access among states. This data helps underscore the variability in palliative care services, staffing, education and research at major cancer centers in the US.

I won't belabor the data here as it is relayed well in the abstract. But a few things impressed me about the study. It made a strong effort to differentiate between the simple question of 'Do you have a palliative care program?' which in a few institutions I have seen consists of a well stocked brochure rack and a single staff member (usually a nurse) who has 20 other job responsibilities that are prioritized by the administration above palliative care. Instead the authors focused on the structure, process and outcomes (also known as a Donabedian tripartite division, but of course you already knew that.)

Also a question to cancer center executive about barriers to palliative care seemed to be somewhat contradictory to other findings. Thee highest rated barriers (around 50-60%) were:

• limited institutional budgets
• poor reimbursement
• limited trained palliative care staff

despite 89% of cancer centers surveyed claiming to have palliative care programs. And conversely very few center executives (less than 10%) reported the following as barriers:

• limited palliative care needs
• lack of evidence for palliative care
• palliative care may increase mortality
• palliative care may affect national rating
• palliative care available but not utilized

So if I understand this right, 89% of cancer center executives have palliative care programs with staff who get paid from the budget but the around 60% feel the biggest barrier to getting palliative care access is that there is no budget/reimbursement or staff?

Couldn't be the culture of cure (see the media study), or the fact they are a tertiary referral center focused on the 'save'? Or the drive to get more patients enrolled in experimental drug trials which is a major source of funding/prestige? Or that palliative care may still not be well integrated into the culture?

I'm merely speculating here, but I think there is a juicy qualitative/anthropological study in this data.

One last thing...only 57% of NCI Cancer Centers had board certified palliative medicine physicians. And the data was collected in 2009. Come on people get board certified in hospice and pallaitive medicine this fall.

(Image from Funnycancershirts.com)

David Hui, MD, MSc, Ahmed Elsayem, MD, Maxine De La Cruz, MD, Ann Berger, MD, Donna S. Zhukovsky, MD, Shana Palla, MS, Avery Evans, Nada Fadul, MD J. Lynn Palmer, PhD; Eduardo Bruera, MD (2010). Availability and Integration of Palliative Care at US Cancer Centers JAMA, 303 (11), 1054-1061

Three Excellent Blog Posts For our Field

I couldn't wait until next month's palliative care grand rounds and so I had to post a link to each of these three wonderful blog posts to make sure you knew about them.

One from Joanne Kenen at The New Health Dialgoue from the New America Foundation:



In the article "This is Why We Need Palliative Care" Joanne comments on an article in the journal Health Affairs called "Shock Me, Tube Me, Line Me." An exceprt from her post:

End of life, he writes, can be done better. He’s correct. It can. "Give me a motorized wheelchair and a feeding tube if I need them, along with a tracheostomy to help me breathe and dialysis to filter out toxins. Those do nothing to stop a good mind and a strong spirit, while permitting both to overcome obstacles of blood and flesh." That's his opinion and his wish.

And two from GeriPal:

Patrice Villars a nurse practioner writes on "Maintaining Relationships: Stop Using the Words ‘Terminal’, ‘Dying’, ‘Hospice’, ‘Advance Directives’ and ‘Bereavement’ that Push Others Away"

An exceprt from GeriPal:

Our audience – patients and families – often don’t want to hear about dying. Death and dying is scary. Scary equals reactionary sound bites (i.e. death panels) that can dash any hope we have of reasonable reform and ongoing open relationships. (Ex. Advance directives talks with your physician = dying = fear = death panel = killing Granny and babies with Down’s syndrome). And guess what other words also equal death to our audience? Terminal. Advance directives. End-of-life. Hospice. Yes, and even bereavement. As long as the majority of our patients/families (to say nothing of our health care colleagues) associate palliative care with dying, they will not have access to our services.

Whoa, this is a lot to take in. You mean don’t use the words we have been using for decades to demystify the fear and denial of death in our culture? Isn’t this who we are? What about the movement we have come to birth, nurture and protect? Really, stop using those words?

11 comments on that one so you know it got people stirred up.

Brad Stuart, MD has an enthusiastic rallying cry for palliative care, hospice and health care reform titled: "Talking Palliative Care and Death: Get Up, Stand Up, Grow Up"

An excerpt:

"Why has dying become “radioactive?” Because Sarah Palin, PR master, made it that way with her Death Panel comment on Facebook. With one (more) semi-conscious crazy-ass remark she made “fear of death” the brand for all end-of-life considerations. And because optics is everything in our surface-obsessed culture, the world bought it. Are we following the world on this one? Uh-oh – I smell fear in the room. In fact a subtle scent of fear pervaded many of the meeting rooms in the Hyde Center last week. Did you notice?

and later...

Let’s talk bottom lines. Below are four fundamental reasons why I believe palliative care is critically important to health care reform. Forget radioactive. Talk about it. Just persevere. Outlast the resistance: this is a basic spiritual principle. Don’t be cowed. If the system is to wake up, that process needs to start in our own minds.

These three articles are as important to our field as any editorial written in JPSM, JPM, NEJM or JAMA.  And now you can make your voice heard go comment on these posts! Share them with your boss and team.

Facebook Friends with a Dying Patient (Via NYTimes)

If you want a better story about the potential for social media to be another tool for connecting people to each other, you won't have to look much further than Daniela Lamas' essay in the New York Times this past week.

As a medical resident she tells of a critically ill man using his laptop frequently in his ICU bed to update his Facebook status. Through a very simple exchange at the bedside, they became friends on Facebook, a new relationship which became much more complex.

The essay is short, but packs several difficult questions that Daniela elucidates very well in the essay. Read it and bring it to your team to see if they have had a similar experience. You may be surprised.

(Photo by Flickr user: brykmantra)

(By the way, I have started a new NYT label.  If anyone wants to help find all the NYT posts and help us label them, that would be great!)

Implantable Cardiac Defibrillators- Hospice Role in Deactivation?

The Annals of Internal Medicine published a survey of hospices regarding their experience with patients who have implantable cardiac defibrillators. (See here for a brief explanation of these devices.)

The survey, conducted by Dr. Nathan Goldstein and colleagues, was directed at hospice administrators with instructions for that person to speak with the clinical staff. Of the 414 hospices that responded (a little less than half of those surveyed), 97% reported having patient(s) with ICDs, 58% reported having at least one patient who was shocked in the last year, and 42% of patients had the device deactivated.

Having a policy on ICD deactivation correlated with patients actually having the devices deactivated (73% of patients enrolled in hospices which had a policy vs. 38% in those without a policy; P < 0.001). The investigators include a sample hospice ICD deactivation policy in the web appendix. They rightly point out that it's impossible to know from this study whether the above correlation indicates a cause-effect relationship. Hopefully, further research is forthcoming. Policy/procedure + education seems to be the key. Without the former, you probably risk having a nurse not having the proper tools/avenues to do what she knows. Without the latter, you risk having inappropriate delays in identifying patients for deactivation and unused or improperly used magnet.

Envision a theoretical scenario: A person with hours to days to live is sent home from the hospital with an active ICD. The ICD has not discharged previously. A hospice nurse frantically calls the medical director during her enrollment visit at the patient's home (on the same day of hospital discharge) because the patient is comatose and has been shocked several times. Perhaps if a hospice policy dictates that nurses seeing patients with ICDs should always have a magnet, this type of scenario could be averted or easily managed. Maybe the magnets are inexpensive enough that every nurse should have one in their car (even though it's not an every day occurence?)

The main point of this case is that someone should have thought about deactivation before the patient was sent home. I hypothesize that most hospice patients with ICDs were hospitalized shortly before hospice enrollment. Regardless of whether this is true, I'll surmise that there is usually plenty of time for the cardiologist/internist/palliative care clinician to come up with a plan for ICD deactivation with the patient or family. Consideration of a hospice referral should trigger any of the above providers to readdress the goals of ICD and consider deactivation, but in many patients, it's appropriate to have this conversation well before hospice referral. So in an ideal world (we're working on it), it should be a non-issue for most patients once they are enrolled in hospice. Goldstein has previously identified barriers that may prevent physicians from bringing up this topic. Maybe hospice nurses don't share these barriers.

Does your hospital, cardiology service, or palliative care team have a policy or procedure for these discussions?

Even if every physician could manage this conversation, some patients would elect to keep the device programmed for discharge at the time of hospice referral. Because of this and the fact that the ideal world won't arrive soon enough, hospices should definitely get to work on their ICD policies and procedures.

Here's more information on deactivating an ICD. (Disclaimer: I have not independently verified the veracity of this information although I do have direct experience with deactivating the Boston Scientific ICD and the instructions listed seem correct- when this device emits a faint beeping sound after a magnet is placed over it, you know it is deactivated. A large household magnet can work but it's probably most effective to have an ICD magnet on hand.)

P.S. The Population-based Palliative Care Research Network (PoPCRN) assisted with the development of this survey. Check them out if you haven't heard of them. PoPCRN's director, Dr. Jean Kutner, just won an AAHPM Distinguished Service Award at the Annual Assembly. Congrats!

Fraudulent Pain Researcher Convicted

Anesthesiologist Dr. Scott Reuben, a prominent pain researcher, has been convicted of falsifying medical research studies.

From BMJ article:

Dr Reuben’s published studies concerned use of multimodal analgesia (a combination of non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors) to manage pain after surgery. The US Department of Justice, which prosecuted him, said that his papers suggested that "multimodal analgesia would be as effective for pain, promote long-term healing, and avoid some of the side effects associated with opioid therapy."

Sadly, he's authored 21 papers in the last 15 years per the BMJ article. Per a Google Scholar search, his name appears to be on many papers.

Here's an AP link in case you can't access the BMJ article.

Symptoms, Suffering, Parents and Pediatric Palliative Care in End-Stage Cancer, Part 1

Dying children present some of the most distressing scenarios for families and clinicians alike. In pediatric patients with advanced cancer there are a variety of forces and goals in-play. Two recently published studies look at the palliative care of children with end-stage cancer and the perceptions and concerns of their parents. Both studies are retrospective, cross-sectional surveys of parents whose children died of cancer at least one year previously. Joanne Wolfe, MD, MPH of the Dana Farber Cancer Institute, Boston was on both research teams.

The one that I will cover first is currently pretty hot in the media. The second is an Australian study that I will cover in another post.

"Considerations About Hastening Death Among Parents of Children Who Die of Cancer" was published as this month’s Journal Club article in Archives of Pediatrics & Adolescent Medicine. The abstract is here, with links to full text html, pdf and free PPT teaching slides. There is a link to video of Dr. Wolfe discussing the study on the Dana Farber Institute Press Release webpage.

----------------------------------------------------------------------

This study interviews 141 subjects, with concomitant medical record review.

Data presented included:

Reported Experience with Hastening Death (HD)

The 4 Questions:

"During your child's end-of-life care period, did you or a family member ever consider asking someone on the care team to give him/her or give you or the family member medications to intentionally end his/her life?”

"When your child was receiving end-of-life care, did you or a family member ever discuss intentionally ending his/her life?"

"Did you or a family member ask someone on your child's care team to give him/her medications or to give you or the family member medications to intentionally end his/her life?"

"Did a member of your child's care team give your child medications or did you or a family member give him/her medications to intentionally end his/her life?"

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

19 (13%, about 1 in every 8) said they had thought about asking a doctor to hasten their child's death

13 (9%, almost 1 in every 10) actually discussed it with caregivers

5 (4%) explicitly asked a clinician for medications to end the child’s life

3 (2%) reported that their child’s life was intentionally ended with medication. In all three cases the medication used was morphine.

Current Views About HD:

Retrospective Hypothetical Scenarios

36% (49 of 136, about 1 in every 3) in retrospect, would have considered discussing HD under certain circumstances with a breakdown of scenarios given.

Uncontrollable pain was the most common circumstance to elicit a hypothetical consideration of HD. 15% would have considered HD for non-physical suffering.

Only 2 parents would have considered HD in circumstances not directly related to the child’s experience, (family witnessing suffering or medical costs).

Endorsement of HD in Vignettes

94% endorsed proportionately intensive symptom management for a terminally ill child with uncontrolled excruciating pain, while only 54% did so in the case of coma; these results did not change when adjusting for race and religiousness.

50% (1 in every 2) endorsed HD in at least one vignette. 59% would agree with a physician discussing HD in the case of a child with terminal cancer in pain or coma.

Of the 19 who considered HD during their child’s EOL course 16 (84%) endorsed HD in vignettes.

In general, being white (not Hispanic) and being not very religious were associated with endorsing HD in vignettes.

In the discussion it was noted that these data are similar to those encountered among the U.S. public with regard to HD and adults at EOL. Existing expert recommendations that it is best for clinicians to have self-awareness of their own attitudes toward HD, and then to hold open, non-judgmental discussions with family members are reiterated. The data suggest that if physical suffering is identified, most parents are open to having discussions about options including legal and effective alternatives, e.g., proportionately intensive symptom management and palliative sedation (both of which imply consideration of the principle of double effect). It was noted that given the sensitive nature of the topic and social desirability bias that HD discussions may have been underreported.

Time magazine covers the article here.

Some thoughts

I think this study highlights the systemic and intrinsic problems in caring for pediatric cancer patients, those of late-treatment and under-treatment of distressing symptoms especially at EOL. In the absence of information on palliative care options, parents are likely to consider HD as a desperate exit plan. It is likely that more than 13% of parents actually consider HD at one point or another. Having a discussion, earlier rather than later, about planning for contingencies of extraordinary symptom presentations, including those that might include significant suffering, is likely to impart important and reassuring information, as well as proactively relieve this likely-to-emerge existential distress for caregivers.

I will continue in this vein in the next post in this two-part series.

On a related note, Dr. Robert Macauley, Pediatrician on the Pediatric Advanced Care Team at Vermont Children's Hospital at Fletcher Allen Health Care wrote an Op-Ed piece in the Burlington, VT Free Press, My Turn: Open palliative care to children.

Palliative Care Grand Rounds 2.3 is up!

Larry Beresford has posted a wonderful Palliative Care Grand Rounds on his blog hosted at Growth House. Thanks Larry for finding some great links! I especially like all the new blogs and posts about grieving and widowhood.

Go over to Larry's blog to see the best of what the blogosphere has to offer in all matters hospice and palliative care.

If you are interested to follow Palliative Care Grand Rounds you can also check out the PC Grand Rounds blog.

The host for April is Tim Cousounis at Palliative Care Success. Send him any blog posts you deem worthy for PC Grand Rounds.

Medicare Beneficiaries and Three Year Mortality After ICU Stay

If you have an older patient who is mechanically ventilated in the ICU, the chances that the patient will die within the next three years seem pretty high when they are in the middle of the acute illness, don't they? But what if that patient survives the hospitalization? What would you say about the patient's long term outlook? The answer will largely depend on individual factors, of course, but I find cognitive dissonance in many scenarios when a patient survives the ICU: The hope that comes with surviving such an illness is pitted against the fear that the illness was a harbinger of worse things to come (especially in the context of chronic illness) . How does this patient population fare in general?

JAMA published a matched retrospective cohort study which examines the outcomes of Medicare beneficiaries after an ICU stay. The study also reports some notable data related to mortality in patients sent to a skilled nursing facility.

The investigators started with a 5% random sample of all Medicare beneficiaries over the age of 65 and divided that sample into two. The first sample comprised the study cohort of ~35,000 patients who survived a hospitalization that included an ICU stay in 2003. The second sample comprised two control cohorts: an "I survived the hospitalization and didn't have to go to the ICU" cohort and a general population cohort. The latter two cohorts were matched with the study cohort based on age, race, sex, and whether the hospitalization had a surgical or medical DRG.

The cohorts on the whole were similar with respect to gender, race, and age. Not surprisingly, those patients admitted to the ICU had a greater burden of comorbid chronic illnesses, and the mechanically ventilated ICU patients were the sickest, with 57% having three or more comorbid conditions.

Some of the results:

• 6 month mortality: ICU survivor mortality was 14.1% (30.1% for those receiving mechanical ventilation) compared with 10.9% for hospital controls and 2.7% for the general controls
• 3 year mortality: ICU survivor mortality was 39.5% (57.6% for those receiving mechanical ventilation) compared with 34.5% for hospital controls and 14.9% for general controls
  
• Discharge to a skilled care facility was an independent predictor of mortality at both 6 months and 3 years, regardless of ICU status during hospitalization (6 month and 3 year mortalities, respectively: 24.1%/54.6% for ICU/Hospitalized controls who went to SNF vs. 7.5%/29.4% discharged home in both cohorts.)
• Readmission to the hospital was a common event in all hospitalization cohorts, but most common in those requiring ICU care (45% in first year for MV patients and 43% for non-MV ICU patients).
  

As a palliative care consultant, have you ever had the experience of being consulted on a really sick patient in the ICU (or anywhere for that matter) only to be called back a short time later with a "consult revocation" because a) it was decided that the patient's prognosis was "better" than initially thought or b) "we're still treating aggressively"? That happens to me occasionally, and my response usually is "we'll plan on seeing the patient anyway, if that's ok." (ie No take backs unless there's a really compelling reason.) This study proves that mechanically ventilated older patients who have a "good" acute prognosis are still faced with a future of uncertainty with more than half having a high burden of comorbidities, close to half requiring recurrent hospitalization in the first year, and close to 6/10 dying in the subsequent three years.

The results are difficult to apply to an individual patient. A previously healthy 70 year old patient who survives mechanical ventilation for pneumonia obviously has a different prognosis than a 70 year old who has end stage renal disease, CHF, and diabetes who survives mechanical ventilation for line sepsis.

But the results should be heeded by hospitals, ICUs, and palliative care teams. Wide variation exists in the volume and type of utilization of palliative care in ICUs. Palliative care is typically consulted when it's clear that the patient is not getting better. As I've said recently, that's not the only type of patient we should be seeing. A poor prognosis need not be certain. The higher mortality/comorbid burdened patients described in this study (especially the mechanically ventilated cohort) could be perfect for palliative care, even though they all survived hospitalization. The challenge to our field would be providing the capacity to meet the demands of this population. Questions that we need to ask of ourselves include:

1. Do we offer a time-limited consultation for advance care planning/goals of care delineation/complicated discharge planning with a plan to "remain on the sidelines" after we've helped answer those initial questions?
2. Or do we provide chronic care for patients like this (really would need increased provider capacity)?
3. Related to 2, what about palliative care at SNFs?
   
4. How many of the palliative care interventions should be "organic" within the ICU (without PC consultation)? How do we best ensure PC issues remain a focus after the patient is discharged?

The answers may depend on the setting but I'm hopeful that some uniform answers will evolve.

Here's the last paragraph in the discussion:

The magnitude of the postdischarge use of skilled care facilities for both ICU survivors and hospital controls and the high long-term mortality for all of these patients call into question whether discharge to skilled care facilities is merely a marker for higher severity of illness with appropriate delivery of care. These patients could have been discharged prematurely from acute care hospitals, and needed a higher level of care than they received. It also is possible that these patients could have had better outcomes if discharged home, but were not able to be sent there due to lack of sufficient support from family or friends to act as caregivers. These findings highlight the need for a much more detailed understanding of the long-term care needs of these patients.

In the age of throughput, there's no doubt in my mind that some of these patients were discharged from the hospital too early. However, I'm bemused in trying to sort out how these very sick patients might have better outcomes at home if they only had better caregiver support, assuming that by "outcome," the authors refer to mortality. The only outcome that might have been better for some of these patients at home would be a palliative care outcome: receiving care in the setting of choice. To that end, I do agree that we need many more details regarding the long-term care needs of this population.

See other related posts on prognosis in the ICU here and here.

(Illustration courtesy of Niels Olson on Flickr. See here for the original, which has scroll over notes.)

Pallimed Readers Task: What did you learn from the Annual Assembly?

It is so wonderful to be able to drink in from the fountain of knowledge and networking that is the 2010 AAHPM / HPNA Annual Assembly, but it is also important to share that knowledge with your co-workers. Since 2006 when the University of Kansas Palliative Care Fellowship (in conjunction with Kansas City Hospice and Palliative Care) started we have had two hours of review scheduled in place of the usual lectures. This serves a purpose for further discussion about important points from the meeting amongst the attendees but even more critical the passing of knowledge to those who could not attend. Why should the knowledge dead-end with you if you went?

At these meetings we encourage attendees to make a one-page handout to distribute highlighting key facts learned.

So this year to pass on the knowledge, I invite all Pallimed readers who attended the Annual Assembly to make a one-page handout for your organization, but to also send it to me so we can share those pearls on Pallimed.

When you send me your handout please use the following basic format:

• Name
• Discipline
• Organization
• It is OK to have a section for General Tips
• For tips from specific talks, please list the Title of the talk (and speaker if you have it)

When you send it to me please specify if you would like to have your tips aggregated anonymously with the whole or published as a whole under your name. A disclaimer on the tips will be made to specify that none of it constitutes specific medical advice and should be verified with other sources.

Even if a few of you send me your handout, we can really crowdsource this (a la Wikipedia) and find out what the major tips were.

Thanks in advance.