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.

Some Highlights from the Web

Nothing too hard hitting in this one, those last two posts wore me out. And I like many other fellowship program directors around the country are busy getting our fellowship applications ready for the first round of accreditations due in the next several weeks.

The Happy Hospitalist found a picture on Flickr took a picture from his service reflecting what he sees regularly. His blog post was then picked up by the WSJ Health Blog. The title of his post was "87 years old" and the caption read: A photo worth a thousand words. Now…. multiply by five. One hospital. One service. One day. Mine. This is American health care. It inspired very different takes on his own blog and on the WSJ Health Blog. Read the comments for a pulse of American view points on aggressive ICU care for the elderly.

The WSJ Health Blog also rediscovered a 2006 National Geographic image about the likely causes of death. The image is called the 'death spiral' although it is really more like a Venn Diagram and each circle within representing the likelihood of occurrence based on the size. The line on the outside...that represents the risk of dying if you are living. Mortality risk 1 in 1. Kind of like the satirical paper The Onion reminded us in 1997.

House calls may be making a comeback as featured in the Boston Globe op-ed, but as many hospice physicians know, there are already a lot of us making these home visits. It is always a delight to see people's expressions when they hear you make house calls. Many really don't believe you until you show up at their home.

On the heels of the Medicare Hospice cuts post, comes this study alerted to us by an anonymous poster that demonstrates wide regional variations in hospice density. Unfortunately it was only a paper presentation and not yet published so all we have to go on is the press release text and a small image map, without a clear legend. I am still having trouble with this paragraph in the press release:

On average, the study found, counties have 2.1 hospices located within their borders, but the number ranges from none to 125. When the researchers looked at 60-mile-radius service areas — the range recommended by the National Hospice and Palliative Care Organization — the average number of hospices serving a county was just over 52. But it ranged widely – from none to 280.

Maybe Dr. Silveira could let us in on what the colors mean, if anyone knows her tell her to drop by and fill us in. (She is the winner of the 2006 AAHPM Award for Young Investigators BTW) Dr. Silveira emailed me the key below.

The colors 'categories' on the map mean the following:
> red - highest hospice availability (taking into account 60mi service area around each office)
> orange -medium
> cream - average
> light blue - low availability
> dark blue - lowest availability
(added April 4/22)

The AAHPM opened the first call for the Annual Assembly 2009 in Austin, TX. I will have an upcoming post on how to submit a proposal to a conference, and will welcome any tips from long time presenters to help anyone relatively new to the process. Also, I will make a plea for someone to submit a Philosophy talk about death and dying so I can go to it next year. We need some contemplative/insightful talks at AAHPM next year. If you do propose it and it gets accepted, I promise to plug your talk here before the next conference and get hundreds of people to show up. Well...at least I promise I will show up.

The Hospice Foundation of America has a good hospice news blog that covers focuses on slightly different topics than we do here. I wanted to alert our readers to a two great links HFA Blog highlighted (1, 2). The Concord Monitor received a Pulitzer Prize for Photography for a series on a dying woman's wish to leave a final gift to her children. There is a wonderful narrated slideshow of the prize winning photographs accompanying the article. The second item is a Guardian (UK) photo exhibit of people photographed alive and on the day they died. Wonderful, touching images that are currently on display at the Wellcome Collection.

And you may have heard about bloggers writing until they die. Well, Drew, Tom and I are doing OK, so don't worry about us!

NOTE: Correction made 4/15/08 in second paragraph. Added hospice color key 4/22/08

Lectures about Death at Yale and Carnegie Mellon

In perusing some of the great (and not-so-great) general education resources from colleges and universities, I stumbled across a philosophy course by Professor Shelly Kagan on Death. Dr. Kagan has written a book called Normative Ethics, which is the study of what is ultimately right and wrong rather than what we believe to be right or wrong. If that doesn't confuse you then this free course might be right up your alley. (There is another session from Yale on Intro to Psychology for those who need a little brushing up.)

The course was originally recorded in the Spring of 2007 and the 26 hour-long sessions are available in mp3, QT, flash or transcript formats. I originally started watching the videos, but since Dr. Kagan does not write on the board much and mostly sits on his desk and talks, I switched to the mp3 formats and have been listening in my car/Ipod. The talks themselves are informative and provide a helpful background into centuries of thought in regards to our current existence and approach towards dying and thoughts of the afterlife. This lecture series is not for everyone, as it can sometimes get pretty abstract, and I occasionally found myself wondering, "Is this a good use of my time? Will this change my practice?" The answers I came to were: Yes and probably not.

I am unlikely to engage many families or patients deeply on issues of spirituality or afterlife as these conversations are usually brief and affirmative of whatever core belief of the patient and family. Rarely are these bedside discussions of spirituality drilled down to the nature of 'what is the soul?' and 'Did Plato's view on forms really support the argument on recollection as a valid theory of existence?' Nor am I likely to have these sort of deep philosophical discussions with staff as we are trying to solve the latest clinical or social challenge in our daily routine. "Yes, let's see if the nausea is better with phenergan...now Heather tell me do you think you are the same person right now as you are in the future?" So to find any value in these lectures I had to realize they help me internally process/understand the suffering/death/joy/relief seen in palliative care on a daily basis. So for those that have the time, enjoy some free Yale teaching! Although I would like to see more philosophical lectures in palliative care education or at national meetings for anyone who would be qualified to give these talks.

"MY LAST LECTURE"

No, not my last lecture but Randy Pausch, the professor from Carengie Mellon University who became an internet sensation when his 'last lecture' was posted to You Tube and seen by hundreds of thousands of people. He recently highlighted some of that talk in an article he wrote for PARADE magazine. (I know, I know...we always cite the New York Times, Washington Post or Newsweek, but hey PARADE is in my Sunday Kansas City Star and he was on the cover...oh never mind.) He was diagnosed with metastatic pancreatic cancer in September 2006 and is still alive today testifying before congress and raising funds for pancreatic cancer research. The video is about 75 minutes, and demonstrates a very constructive approach to such a life-changing event. (He is also a very good presenter, so take notes on his style, use of slides, speech and engagement with the audience.)





MENTORING

The AAHPM and the College of Palliative Care are continuing the Year-Long Mentoring Program and the deadline is May 19, 2008. I have been fortunate enough to benefit from this program in being mentored by Paul Glare with a focus on Prognostication. Because of the collaboration this mentor program facilitated, I have been able to co-author a textbook chapter, and write a few journal articles on prognostication, and will soon traveling to meet with Paul and discuss prognostic research and some editorial articles I am working on. As you can see this is a great opportunity, so if you are just a few years out of training, consider applying.

If anyone is interested in working on prognosis, Pallimed/medical blogs, or other topics, I'll throw my hat in to be available to work with someone as a mentor. The AAHPM could also help in identifying a mentor. Don't be afraid to aim for the stars, as I had initially asked Nicholas Christakis (author of a seminal palliative care book, Death Foretold), but he said he was no longer doing prognosis research and referred me to Paul Glare as the go-to guy in the field on prognosis. They both have been great and supportive.

FELLOWSHIP PROGRAMS

Last week was the Fellowship Program Director annual meeting in Chicago, where we discussed the future accreditation of Palliative Medicine Fellowship Programs for July 2008. There is a lot of work to be done and forms to be filled out, and most importantly a lot of collaborating between hospice and hospitals to make sure that fellowships are well balanced. So what does it take to be a palliative medicine doctor and how do you know this is the field for you? If you are a palliative medicine fellow, recently finished fellow or faculty and want to write a guest post on what it takes, please email me at:

Reasons for PAS; Prognosis in TBI; More

I'm traveling the rest of the week & this will be my only post until March, which I'm hoping will host fewer record-breaking snowfalls in the upper Midwest than January and February have.

1)
The Journal of General Internal Medicine has an article about family perceptions of why their loved ones pursued physician assisted suicide. It involved interviews of ~80 patients who had pursused PAS in Oregon (about 50 actually received prescriptions and 30 went through with ingestion of the lethal prescription). Family members were interviewed between 3 months and 3 years after the patient died. It's somewhat unclear to me how these people were identified: it looks like an advocacy group has a database of people who had inquired about PAS and the family members were identified that way (it doesn't seem like it was an exhaustive list of everyone who pursued to whatever extent a lethal prescription in Oregon in the time frame of interest for the study). 38% of family members approached participated in the survey.

The general demographic profile of the patients underscores previous findings that people who pursue PAS are white, predominantly male, and overwhelmingly receiving hospice services (87%). Family members perceived their loved ones pursued PAS for reasons of autonomy/control and fear of future suffering: wanting to control the circumstances of death, not wanting to be a burden in the future, fearing loss of independence and dignity in the future, and fear of symptoms in the future. The importance of current symptoms (current at the time the patient initiated pursuing PAS) were, however, minimal.

There are a lot of limitations to the study: retrospective, relies on family reporting long after the fact, and a low response rate. Nevertheless the findings are consistent with other studies examining why people pursue assisted suicide - it is very much for existential reasons - people who cannot conceive that the decline and indignities of dying could be meaningful or valuable in any way - and not because people's current physical suffering is driving them towards 'desperate' measures. I think this has importance to the debate about PAS, especially since its proponents often tout it as a necessary safe-guard against dying in agony. Besides not being true, that's also not why people seek it, and the only debate about it which makes sense to me is one that centers on rights & autonomy (the rights of an individual to decide what constitutes a good death for them by controlling its circumstance) but not a debate about preventing (physical) suffering. The vast majority of physician proponents of PAS of course are not promoting it as a safe-guard against physical suffering, but some of the patient/'consumer' advocates of it are, and aren't afraid to bring out the scare-mongering language.

I'll also note that this article calls PAS 'physician assisted death' (as does the AAHPM position statement - although I'd encourage you to click that link then actually look at what the URL of that page says!) throughout. While the article, and the AAHPM statement, are explicitly about the practice otherwise known as PAS, others use 'PAD' (or at times, 'assisted death') as a blanket term to include both assisted suicide and euthanasia, making the use of PAD strictly for PAS confusing. I agree with the AAHPM statement that the word suicide is emotionally charged but that doesn't necessarily make it inaccurate and insofar as there are others using 'PAD' to include euthanasia one wonders if changing the language in this way is actually helpful. Curious as to readers' thoughts about this. I'm sticking with PAS for the time-being.

Ganzini, L., Goy, E.R., Dobscha, S.K. (2008). Why Oregon Patients Request Assisted Death: Family Members Views. Journal of General Internal Medicine, 23(2), 154-157. DOI: 10.1007/s11606-007-0476-x

2)
BMJ has a study about developing a prognostic model for traumatic brain injury. The data were prospectively gathered and come from an international study of TBI (10,000 patients with a 20% 14 day mortality and a 37% 6 month 'poor outcome' across the cohort). Poor outcome here is defined as death or severe disability & severe disability is defined as 'able to follow commands/unable to live independently' or worse. All the usual prognostic model derivation and validation hoops were jumped through (well, most of them) and they created a couple prognostic models (a simple one and a more complex one using specific CT scan findings). Given the large size of the studythey achieved a tight fit between their derivation and validation cohorts. The simple model uses easily available data: Glasgow coma score, age, presence of major extracranial injury, and pupil reactivity upon presentation. They created a handy web-based calculator for 14 day mortality and 6 month 'poor outcome' prediction.

While death is an easily agreed upon 'poor outcome,' the 6 month outcome is more problematic. Assuming this model is incredibly accurate, and you could use it to predict a 95% chance of a poor outcome at 6 months, this still represents a wide spectrum of cognitive and functional disability (from death to persistent vegetative state to, presumably, a cognitively intact or nearly intact patient whose medical issues were sufficiently complex to prevent a return home). I imagine this is going to be insufficiently precise to be sufficiently helpful to many family members and clinicians for improving decision-making (it would be more helpful if it gave an outcome for PVS and death alone, for instance). What we need, of course, is a prognostic model which will tell your family if your outcome will be sufficiently positive that you'd want ongoing life-prolonging care after a severe TBI; this is also known as a crystal ball and one has to forgive these researchers for not coming up with it.

One of the accompanying editorials talks about the limits of the model, and cautions against using it in clinical care (instead promoting it for risk stratification of patients for further research). I think the cautions are valid, however prognosis is always limited, human, and incomplete and suggesting that we need perfect prognostic powers before making decisions is strange to say the least. A quote:

Far greater caution is needed if such a model is to be used for making decisions about treatment in individual patients. Estimates of outcome probability from the 10 000 patients in the CRASH trial are based on collective clinical experience beyond that achievable by any individual clinician, and these estimates may help educate clinicians and support clinical decision making. They cannot be used in isolation, however. Models can estimate the probability of a given outcome for a group of clinically similar patients with a high degree of accuracy, but they cannot reliably predict outcome for individuals. At least in the context of deciding whether or not to treat individual patients, it is important to continue to acknowledge, as did physicist Niels Bohr, that "prediction is very difficult, especially about the future."

Thanks to Dr. Bob Arnold for alerting me to this.

3)
And very briefly:

• JAMA has a study about survival of in-hospital cardiac arrest. The paper uses prospectively gathered data on ~80,000 in-hospital arrests (from a national registry) and compares outcomes for pulseless cardiac arrests that occur during weekdays vs. those that occur on nights or weekends. Overall survival to discharge was 18%; 14% survived and had good neurologic outcome (how this was actually determined is unclear to me). Pursuant to a recent conversation on the blog, the best outcomes were intraoperative arrests during the day (night ones weren't too good presumably because these were emergency surgeries on unstable patients): 36%. (For the record, outcomes are modestly better during weekdays than nights/weekends.) These figures are in the ballpark of previous studies. I'm curious as to whether in the next decade or so rates of in-hospital arrest will start improving due to better patient selection (fewer resuscitations of the otherwise dying); that of course assumes such trends are actually occurring....
  
• Scanning through the references from the JAMA piece I noticed this one from a few years back that I had never seen. It caught my attention because they evaluated outcomes of arrests for people with 'limited resuscitation' status (e.g. 'partial - as in not 'full' - code status: people whose code status limits intubation, shocks, or chest compressions but not all three) - I had never seen a study looking at this. None of the patients who had a 'limited code' status survived an arrest to discharge, which is at least a wee bit of evidence to support the long held adage that partial codes make no sense. A long time ago I had a (very sick, but smart and seemingly well-informed) patient who could not understand why her code status couldn't be "one shock, nothing else."
• The Journal of Clinical Gastroenterology has a study about prognosis in advanced pancreatic cancer based on retrospective analysis of data from a Korean cancer center.
• To the Best of Our Knowledge, a public radio show, this week has an hour long segment on the good death. It's worth listening to (you can stream it online; there's also a podcast available at iTunes).

Pediatric Palliatve Care Barriers; Palliative Med Salaries

1)
Pediatrics, the journal of the AAP, occasionally features palliative care issues, so when my wife's copy arrives I usually take a quick look at the table of contents. In the February issue they feature an article on the Barriers to Palliative Care for Children as perceived by health care providers. Davies et al polled all staff members (698) at UCSF Children's Hospital, and reviewed the results from the 117 nurses and 81 physicians who replied. Of the remaining 42 respondents they were from other disciplines and there were not enough to make significant comments as a group. The majority worked in NICU and PICU where you would expect they would see at least a few pediatric deaths per year, and only 9% of the respondents said they had cared for zero patients who died in the previous year. About 25% of the physicians had experience with more than 10 pediatric deaths in the past year, which makes the 'rarity' of pediatric deaths seem not so rare, at least in the hospital setting.

The bulk of the article is dedicated to reviewing the frequency of multiple barriers identified by the staff. #1 - Uncertain prognosis - was not too surprising, and ties in closely with the #2 reason - Family not ready to acknowledge incurable condition. These two reasons are intimately related and are joined by the skill to adequately communicate medical information, probabilities and uncertainties, and the ability (for staff and patient/family) to hold out for hope but accept the probability of decline. Given the plasticity of children to rebound from devastating illness and trauma, and the myriad of rare congenital conditions it is understandable to see why prognosis is difficult to outline for any one patient. Just because it is difficult doesn't mean we as a field should not try to make a larger commitment to finding what prognostic factors bode for good and poor outcomes across various disease entities. And if it comes down to the clinician's prediction of survival, we need to know the accuracy, precision and biases for pediatric predictions just as much as we need to study medical predictions in adults. These two reasons also make it much easier to advocate for early concurrent palliative care involvement. But I know from talking to pediatric palliative care colleagues is they suffer from 'We're not ready for you yet, because they aren't dying." similar to adult palliative care teams.

The authors explain this well:

"We think that clinicians need to realize that uncertainty is not something to be avoided but rather is an inherent dimension of care. An uncertain prognosis should serve as a signal to initiate palliative care, rather than to avoid it, even when it is not yet appropriate to begin EOL care."

One large difference between adult & pediatric palliative care barriers highlighted is pediatric staff do not identify addiction fears, hastening death or legal action as significant or frequent obstacles. Some of these results seem discordant, for example: less concern with hastening death does not seem to fit with a large concern with an uncertain prognosis. Both have to do with the predicted timeline, and if you are uncertain where on that timeline death will occur, then by extension you may be concerned that your actions may hasten death. I do commend the researchers on using the neutral and descriptive term of 'hasten death' as opposed to the oft-confused terms euthanasia and physician assisted suicide, which we have covered here at Pallimed before.

Overall the study was well done, and had a good response rate, although it was only at one institution so hospital culture issues may exist as biases in this study.

Davies, B., Sehring, S.A., Partridge, J.C., Cooper, B.A., Hughes, A., Philp, J.C., Amidi-Nouri, A., Kramer, R.F. (2008). Barriers to Palliative Care for Children: Perceptions of Pediatric Health Care Providers.. Pediatrics, 121(2), 282-288. DOI: doi:10.1542/peds.2006-3153

2)
As fellows start looking for future jobs, it is important to understand what physician salaries are like out there. These few links provide some basic information across different specialties (not palliative care) and as you can see the variation is wide. There is currently a MGMA survey for Palliative Care physicians (via AAHPM). I went through some of the initial steps, but as you get further into the survey it looks like your billing/administration department needs to be able to answer some questions. It is a bit more complex then how much did you make, and how much does it cost to employ you. I may put some of the areas for questions in the comments section if people are interested.

Regardless most people will tell you that you probably should not be going into palliative medicine if you are expecting to make loads of money. It is a 'thinking' and talking' medical specialty after all, but there are many other tangible rewards in the work that you can do. (links from A Physician on Job Search and Practice via KevinMD)

Back From the AAHPM /HPNA in Tampa

Drew and I appreciate all of the wonderful feedback we received while in Tampa at the AAHPM/HPNA Annual Assembly last week. Thanks to all the readers who proudly wore the "P" sticker and who came to Backjack's to meet with other Pallimed readers. It was good to match faces to names. If I missed you there or didn't have much time to chat, I apologize. For being there less then 24 hours it was quite an exhausting pace.

We heard a lot of interesting comments about the conference as well. I wished I could have made it to more than just the Case Conferences on Saturday (which were great BTW). So to make up for all of my lengthy posts about what I thought were interesting talks, I would like to turn the rest of the post over to the readers.

Please comment on the talks that you thought were remarkable or avoidable or what would you like to see next year, etc. Remember we are not an official part of AAHPM/HPNA, but just wanted to open some discussion about what Pallimed readers thought was important. (And if this is your first time to Pallimed, welcome!)

Race and hospice revocation; COPD; Nabilone for pain; Much more

This is my first post for a couple weeks and I have amassed a large backlog so my next few ones will likely focus on a single article and then mention others only in passing.

Thanks for everyone who said Hi in Tampa, or who came to the happy hour (M. sorry about the loud music - it's too bad Wham! is not your cup of tea). Tom Q - we missed you.

A quick note about the Blogging on Peer-Reviewed Research and Research Blogging system that we have alluded to before. The Research Blogging website is now officially up and running. It is, among other things, an aggregator of all blog posts by bloggers who use the BPR3 standards - it's an organized attempt to promote 'serious' academic blogging & we are hopeful it will be successful.

1)
Archives of Internal Medicine has published a fascinating article about race and hospice revocation to pursue 'aggressive' care. It is a retrospective analysis of data from a multi-state hospice group and compares characteristics of white patients who revoked their hospice enrollment to pursue aggressive care (the hospice agency prospectively gathered data on reason for hospice revocation at the time of discharge).

In some ways, simply the epidemiologic data are interesting: over 5 years 167,000 patients were discharged alive and only 2.8% of these were to pursue aggressive care, a median of 22 days after enrollment. This is, then, a rare event. African-American patients were more likely to disenroll to pursue life prolonging care (4.5% vs. 2.5% of whites), and this difference survived controlling for age, income, diagnosis, and other demographic variables. Length of stay, age under 65 years, non-cancer diagnosis, and not having an identified caregiver were also associated with revocation to pursue life-prolonging care.

What I found most notable was the 1 year survival amongst those who revoked hospice to pursue life-prolonging care: 48% (for both African-American and white patients). Those who died after revocation did so relatively quickly (~40 days), but almost half were alive at the end of a year. The authors note that those 40 days of survival are only a couple weeks longer than median survival in hospice, suggesting that those who died probably didn't have their lives prolonged much by revoking hospice. The relatively long survival of the others suggest that the decision to enroll in hospice was wrong (at least from a prognostic perspective). This data may be out there, but I know of no other good study looking at long-term outcomes for those who voluntarily revoke their hospice benefit. Of course, there are other important outcomes than 1 year survival, and we don't know what those years looked like, but that's for another study.

The authors discussed possibilities as to why African-Americans may revoke hospice care more than whites (and thankfully avoid pathologizing these decisions as due to 'mistrust' which implies a sort of irrationality). They do propose this explanation, which is pure speculation, but quite novel I thought:

"However, because African American patients are less likely to participate in advance care planning, they may spend less time thinking about or discussing their preferences for end-of-life care before enrolling in hospice. Because hospice care facilitates advance care planning, hospice enrollment may provide African American patients with the opportunity to solidify and discuss their treatment preferences. When these preferences conflict with the hospice philosophy of care, they may withdraw from hospice."

Johnson, K.S. (2008). Racial Differences in Hospice Revocation to Pursue Aggressive Care. Archives of Internal Medicine, 168(2), 218-224.

2)
Clinics in Chest Medicine recently had a review on 'end of life considerations' for chronic lung disease (mostly COPD). It's a general overview, well written, and notable for its very practical, straight-forward discussion of end of life communication towards its end. It is quite matter of fact about things, and directly addresses physicians' own discomfort in discussing death and dying (something that is often missing from such discussions; it's great to see this in a journal like this). This paragraph was also appreciated:

"Frequently, part of the decision for patients with lung disease is whether they want to receive CPR in the event of cardiac arrest. In our opinion, in helping patients make this decision, it is important that advanced cardiac life support not be broken into components but rather presented as a package. Breaking advanced cardiac life support into components (chest compressions, antiarrhythmic drugs, vasopressor agents, intubation) makes these decisions unnecessarily complex and can lead to an absurd resuscitation status, such as compressions and all drugs but no intubation."

3)
BMJ has a trial of a cannabinoid vs. an opioid for chronic neuropathic pain. It is a randomized, blinded, placebo controlled cross-over trial which compares nabilone (a synthetic cannabinoid) with dihydrocodeine (an opioid unavailable in the US about which I know little). Each patient was randomized to 6 weeks of the study drug and then crossed over to the other drug after a 2 week washout; patients could go through a dose titration protocol for each drug as needed for pain control. Both groups had lots of drop outs and the authors present per protocol analyses mostly. Dihidrocodeine did a little better than nabilone, although frankly both come off as crummy analgesics (few in either group achieved a 1 point drop in their pain on a 0-10 scale). Not a great endorsement of either cannabinoids or weak opioids for neuropathic pain.

4)
Very briefly:

• Social Science & Medicine has a recent article about hospice & Medicare cost savings (it's a case control study and tries to establish what is the ideal length of time for someone to stay in hospice, from a Medicare cost savings standpoint - the answer, thankfully, is much longer than the median hospice stay).
  
• JAMA recently had a commentary about definitions of disability. It was placed in the context of an 'impending wave' of population disability. There was something in the way the authors discussed how disability is conceptualized and medicalized which seemed, to me, consonant with how death is medicalized. I'm not suggesting this is a perfect analogy, at all, but thought I'd throw it out for the more anthropologically minded reader. See here:
  
• "By the late 19th century, the medical model of disability was firmly entrenched. "The medical model views disability as a problem of the person, directly caused by disease, trauma or other health condition. . . . Management of the disability is aimed at cure or the individual's adjustment and behaviour change. Medical care is viewed as the main issue." The medical model thus built upon 2 assumptions: first, that individuals should strive, largely through their own efforts guided by physicians, to overcome disabilities; and second, that physicians know what is best for patients. Both assumptions often made disability a lonely state—defined and frequently stigmatized by others, with individuals required to "cheerfully and unselfconsciously" make their own "good adjustment."
• Radio Lab, a public radio show which is usually about science, thought, and Big Ideas, recently put out a podcast about music written for a morgue of sorts (a viewing chamber at a hospital for the family to see the recently deceased). You can listen/download here.
  

Make the Most of A National Conference - 4th Edition

OK, I know I said that the last post was the last one about the conference, but this one is about conferences in general.

I compiled this list of helpful hints from my own experiences and from peers input over the past few years. I think it may be helpful to first timers but also to veterans of national/regional meetings like the American Academy of Hospice and Palliative Medicine (AAHPM) Annual Assembly. I have reorganized the list into with some prioritizing/categorizing and added more content on presenting. I have also made the language more neutral to apply to any conference, besides Palliative Medicine.

This was originally posted to the AAHPM Professionals-in-Training Special Interest Group email list.

Any comments are appreciated. Feel free to agree/disagree or add hints.

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Christian Sinclair's Handy Hints for a National Meeting
Originally written Jan 2005, Updated 2006, 2007, 2008

General

* If you are bringing family or a significant other, make sure to spend some time with them.
* Bring business cards, lots of them. Make sure they have your email on them. If they do not write your email a number of the cards so when you hand them out, you are not trying to find a pen right then to add it.
* When you get a business card from someone else, immediately write down what you were talking to that person about. If the time isn't right, then do it soon afterwards. When you get home, you will have met so many people, you won't remember w