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Friday, July 26, 2019

March Madness, Palliative Care Style

by Sarah Rossmassler (@srossmassler)and Diane Dietzen (@ddietzen)

As a part of our palliative care team’s educational efforts for the medical residents at Baystate Medical Center, a 712-bed tertiary care academic medical center in Springfield, MA, we prepare and present an academic half-day about twice a year. This year, since our turn came in March, we organized the teaching around a March Madness theme. We had a ton of fun preparing it and felt it was an engaging format for both the palliative care faculty and the residents. In the spirit of Christian Sinclair’s call to use the format in palliative care (as NephMadness has done so beautifully) we wanted to share what we learned and offer our materials and pearls of wisdom to the PalliMed community.

What we did
We began by having palliative care faculty members select two articles from the recent palliative care literature within four topic areas: communication, goals of care, symptom management, and existential distress. For the first round (about 70 minutes), each faculty member had 7-10 minutes to present their two chosen articles to the residents. Faculty volunteers were responsible for researching and identifying their own papers; we asked each faculty member to choose one review article and one recently published paper that would educate residents in palliative care competencies. We assigned two faculty to each topic area in order to provide a well-rounded and representative selection of papers.

After each of the first presentations, the residents voted for one article they found most relevant to their practice. Then we broke into groups of 4-6 residents with roaming faculty preceptors; the small groups allowed residents to delve deeper into the papers and to discuss which paper they felt was most influential and valuable to integrating palliative care into their practices. Faculty had prepared one-page summaries with insights about why they thought the paper was important. We tried to tailor the summaries to the resident perspective, as most are focused on primary palliative care. Next, we came together as a group to continue voting. After residents voted for each of the next pairings of papers we ended up with a final winner.

What worked well
The competitive nature of the format made it fun for both faculty and residents. The faculty member whose paper was voted the winner was promised a prize by our medical director: a jug of local maple syrup… highly coveted! This added to the excitement on the faculty side, and the residents quickly realized that faculty were competing for their selected papers to win. This prompted some good-natured “trash talking” and faculty efforts at persuading the residents to vote for their papers. We believe that the clear bracket framework allowed the residents to quickly review and engage with a broad selection from the palliative care literature.

What could have been better
We used lots of different technologies, and we should have had a test run prior to showtime in the actual room where we had the event. For instance, the YouTube link was expired; which meant our introductory video had to move later in the session, which might have led to confusion about what the theme of the event was. Also, because there were so many transitions (eight different presenters, fifteen voting opportunities) we struggled to hold resident attention and keep faculty on track. We received constructive feedback that some residents felt the organization could have been tighter and that an introduction to the theme would have been helpful for context (some were not familiar with basketball or March Madness). Some residents wished for more clear take-away points. The pace was fast; to those who were not paying close attention, it might have felt frenetic.

Final Thoughts
The March Madness themed academic half-day was a huge success. Since the work was distributed preparation was manageable for our eight interdisciplinary faculty . The advantages of the format are that it includes nerdy paper reviews, showcases the interdisciplinary nature of the palliative care team, and being interactive, it kept the attention of our resident physicians. We loved that the residents selected our Chaplain’s paper on Addressing a Patient’s Hope for a Miracle as their final winner; it showed us that this is clearly a difficult topic for residents and faculty alike.

The Winning Paper
Shinall, M. C., Stahl, D., & Bibler, T. M. (2018). Addressing a Patient’s Hope for a Miracle. Journal of Pain and Symptom Management, 55(2), 535-539. doi:10.1016/j.jpainsymman.2017.10.002

If you want to try our format…
We’d be happy to share what we did. We made:
  • A two-minute video to showcase the theme (with AC/DC Thunderstruck as the score)
  • An interactive excel spreadsheet with the brackets
  • We used Turning Point for the voting. Consider having a tech person on site to manage the interactive technology (we had our tech-savvy librarian there).
  • If you would like our materials (youtube video, excel brackets) e-mail sarah.rossmassler - at -

Sarah Rossmassler works on the palliative care consult team at Baystate Medical Center in Springfield, MA. She recently completed her DNP at the MGH Institute of Health Professions during which she developed and implemented a QI project with Trauma Surgeons, teaching them the Best Case/Worst Case Communication framework. This work has spurred further interest in other types of graphic aids as communication tools for patients, families, and interdisciplinary teams. In her free time Sarah is caretaker of two mini donkeys (Luna and Mabel) who teach her daily about the importance of staying grounded.

Diane Dietzen is the Medical Director of the Palliative Care Program at Baystate Medical Center and is board certified in Internal Medicine and Hospice and Palliative Medicine. Prior to joining Baystate in 2011, Dr. Dietzen planned and developed a Palliative Care Program at the Abington Memorial Hospital in suburban Philadelphia. Dr. Dietzen served as an Associate Director of the Residency Program educating Internal Medicine Residents. Dr. Diane Dietzen earned her Medical Degree and completed her Internship and Residency at the Temple University School of Medicine.

Friday, July 26, 2019 by Pallimed Editor ·

Monday, July 22, 2019

Living an Intentional Life: This is Water

by Bob Arnold (@rabob)

I am not sure what led me to go from thinking about data and evidence in the literature to waxing philosophical recently. It may be that I saw Rufus Wainwright in concert and heard him sing “Hallelujah” with his sister, Lucy Roache Wainwright (Google it). It may be that one of our cardiology fellows died suddenly of unknown reasons and everyone at my hospital is a little fragile. Or that I was just on service and trying to balance the existential realities of sadness and dying with teaching learners and dealing with institutional budget cuts. But when I sat down today and tried to think of what article to review what popped into my mind was David Foster’s Wallace’s 2005 Kenyan commencement address.

This is where I go to whenever I am feeling philosophic. I go to it because it, more than anything else I’ve ever read, summarizes the human experience, what is real about it, and what is hard about it. And so, it reminds me of how hard it is to stay present, be curious, and think about is “just in my head”. It is too long for a blog post (and I hope you’ll go here to read or watch it). So what I am going to do is give you some illustrative quotes and then a couple of comments.

There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says "Morning, boys. How's the water?" And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes "What the hell is water?"

The point of the fish story is merely that the most obvious, important realities are often the ones that are hardest to see and talk about. Stated as an English sentence, of course, this is just a banal platitude, but the fact is that in the day-to-day trenches of adult existence, banal platitudes can have a life or death importance.

Think about it: there is no experience you have had that you are not absolute center of. The world as you experience it is there in front of YOU or behind YOU, to the left or right of YOU, on YOUR TV or YOUR monitor. And so on. Other people's thoughts and feelings have to be communicated to you somehow, but your own are so immediate, urgent and real.

As I'm sure you guys know by now, it is extremely difficult to stay alert and attentive, instead of getting hypnotized by the constant monologue inside your own head (may be happening right now)….It means being conscious and aware enough to choose what you pay attention to and to choose how you construct meaning from experience. Because if you cannot exercise this kind of choice in adult life, you will be totally hosed. Think of the old cliché about quote the mind being an excellent servant but a terrible master.

If you're automatically sure that you know what reality is, and you are operating on your default setting, then you, like me, probably won't consider possibilities that aren't annoying and miserable. But if you really learn how to pay attention, then you will know there are other options. It will actually be within your power to experience a crowded, hot, slow, consumer-hell type situation as not only meaningful, but sacred, on fire with the same force that made the stars: love, fellowship, the mystical oneness of all things deep down.

Because here's something else that's weird but true: in the day-to-day trenches of adult life, there is actually no such thing as atheism. There is no such thing as not worshipping. Everybody worships. The only choice we get is what to worship.

It is about the real value of a real education, which has almost nothing to do with knowledge, and everything to do with simple awareness; awareness of what is so real and essential, so hidden in plain sight all around us, all the time, that we have to keep reminding ourselves over and over:

"This is water."

"This is water."

It is unimaginably hard to do this, to stay conscious and alive in the adult world day in and day out.

So, what does all this mean for us as palliative care clinicians (or humans)? First, I think it reminds us how easy it is to see our daily lives as normal. I love rounding with first-year medical students who are just amazed that clinicians walk in on people and have conversations with half naked people, sometimes while getting on or off the toilet. That we have difficult conversations in rooms where there is a patient next door (and the cleaning person, dietician and four other people coming in and out). It is so easy to become numb to the hospital experience that you do not realize how completely bizarre it is and how off-putting and alien the experience of health care is.

Second, the stories that I tell in my head about patients, families or other clinicians are just that - stories that I tell in my head. I need to lose my certainty about the story and gather information about the other stories in the world. I need to continually ask myself whether my reactions are because of what is going on in the world, or what is going on in my head.

Finally, I need to cut myself a break. It is really hard given that the only experiences I have are my experiences, to get caught up in that experience. So much of what was resiliency activities (like meditation) are about helping me maintain my awareness and give me choices over what I see and what I do. My days are hard and the budget cuts suck. When I get knocked off balance, realizing that this is the human condition, helps gets me up the next morning, appreciate what I have and move forward.

Next week, I go back to reviewing articles.

Robert Arnold MD is a palliative care doctor at the University of Pittsburgh and a co-founder of VitalTalk. He loves both high and low brow comedy (The Good Place and Nanette), pop culture (the National Enquirer and Pop Culture Happy hour) and music of all kinds (not opera tho!)

Monday, July 22, 2019 by Pallimed Editor ·

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